Effectiveness of cryotherapy treatment for cervical intraepithelial neoplasia

Randomized controlled study for comparison of efficacy and safety between thermocoagulation and cryotherapy in visual inspection with acetic acid positive cervical lesions

Background

Less literature is available on the performance of thermocoagulation for treatment of premalignant cervical lesions and its comparison with cryotherapy from low- and middle-income countries like India.

Materials and Methods

: A prospective randomized controlled study was done in the Department of Obstetrics and Gynecology from August 2018 to September 2019 after obtaining ethical clearance from Institutional Review Board (Reg no: ECR/262/Inst/Up/2013/RR/16) Ref no: 278/Ethics/R. cell-18). A total of 68 women with Visual inspection with acetic acid (VIA) positive cervical lesion were randomized into two groups. Group A was treated with cryotherapy and Group B was treated with thermocoagulation. Estimates of cure, adverse effects or complications were presented as frequencies, percentages, and mean ± standard deviation.

Results

Out of 667 patients, 624 patients underwent VIA testing among which 68 were VIA positive (10.89%, 68/624). The efficacy of thermocoagulation was 93.54% and that of cryotherapy was 90.32%. Immediate side effects were significantly lesser in thermocoagulation group (P = 0.008) in comparison to cryotherapy.

Conclusion

Thermocoagulation is better treatment modality than cryotherapy for VIA-positive cervical lesions may not be in terms of efficacy but definitely in terms of patient comfort and safety.

Policy Considerations to Promote Equitable Cervical Cancer Screening and Treatment in Peru

Background:

Cervical cancer is one of the leading causes of death among Peruvian women. Women seeking screening or treatment services experience delays in receiving screening results provided at community clinics or district hospitals, and lack sufficient resources to pay out-of-pocket to travel to the capital city of Lima for specialized treatment. Continued disparities in health outcomes and systemic barriers to accessing services suggest there are gaps between policy measures and implementation.

Objectives:

We aim to understand why national policies and clinical pathways that are aligned to global standards have been insufficient in improving cervical cancer screening and treatment in Peru, particularly among women who experience systemic exclusion from health services.

Methods:

We conducted a policy analysis based on a literature review (2005–2020), in Spanish and English, on PubMed, Global Health, Scopus, EconLit, Lilacs, and Scielo using a value-based care framework.

Findings:

The main barriers included unequal distribution of health infrastructure and health care workforce, and differences in access to health insurance. Additional barriers, including limited political will and support, limit efforts to prioritize the implementation of cervical cancer policies. We propose policy considersations in redesigning payment models, expanding healthcare workforce, generating costing and policy evidence, and reviewing policies for point-of-care technologies.

Conclusions and Recommendations:

The barriers identified in this literature review are applicable not only to cervical cancer care, but to primary health care in Peru. Systematic policy changes that address root causes of health inequities and are implemented at scale are needed to advance health reform efforts.

Radiologic-pathologic analysis of increased ethanol localization and ablative extent achieved by ethyl cellulose

Ethanol provides a rapid, low-cost ablative solution for liver tumors with a small technological footprint but suffers from uncontrolled diffusion in target tissue, limiting treatment precision and accuracy. Incorporating the gel-forming polymer ethyl cellulose to ethanol localizes the distribution. The purpose of this study was to establish a non-invasive methodology based on CT imaging to quantitatively determine the relationship between the delivery parameters of the EC-ethanol formulation, its distribution, and the corresponding necrotic volume. The relationship of radiodensity to ethanol concentration was characterized with water-ethanol surrogates. Ex vivo EC-ethanol ablations were performed to optimize the formulation (n = 6). In vivo ablations were performed to compare the optimal EC-ethanol formulation to pure ethanol (n = 6). Ablations were monitored with CT and ethanol distribution volume was quantified. Livers were removed, sectioned and stained with NADH-diaphorase to determine the ablative extent, and a detailed time-course histological study was performed to assess the wound healing process. CT imaging of ethanol-water surrogates demonstrated the ethanol concentration-radiodensity relationship is approximately linear. A concentration of 12% EC in ethanol created the largest distribution volume, more than eight-fold that of pure ethanol, ex vivo. In vivo, 12% EC-ethanol was superior to pure ethanol, yielding a distribution volume three-fold greater and an ablation zone six-fold greater than pure ethanol. Finally, a time course histological evaluation of the liver post-ablation with 12% EC-ethanol and pure ethanol revealed that while both induce coagulative necrosis and similar tissue responses at 1-4 weeks post-ablation, 12% EC-ethanol yielded a larger ablation zone. The current study demonstrates the suitability of CT imaging to determine distribution volume and concentration of ethanol in tissue. The distribution volume of EC-ethanol is nearly equivalent to the resultant necrotic volume and increases distribution and necrosis compared to pure ethanol.

Factors that Affected Women Undergoing Cryotherapy Following Cancer Screening with Visual Inspection of the Cervix Using Acetic Acid Method

BACKGROUND

The Indonesian government has applied the cancer "see and treat" method which involves a visual inspection using acetic acid (VIA), followed by a cryotherapy procedure, to reduce the incidence of cervical cancer. However, compliance with the program is still low in the targeted population. This study aims to see what factors influence women to receive cryotherapy treatment if they have positive VIA result.

METHODS

This cross-sectional study was conducted among 356 VIA positive women, aged 30-50 years old, registered at Temanggung District Health Office, Central Java, Indonesia between March 29 and April 31, 2018. Data on whether subjects underwent cryotherapy, their demographic profile, education, knowledge about cryotherapy, and family support were collected in a direct interview using a structured questionnaire. A statistical analysis was carried out to observe the influence of all the variables on subjects' decisions on cryotherapy.

RESULTS

In our study, 217 women (60.69%) received cryotherapy, while 139 women (39.04%) did not. Among all the variables analyzed, the factors affecting the subjects' likelihood to undergo cryotherapy are their knowledge about cervical cancer and screening (PR=0.776;95%CI=0.660-0.913;p=0.003), their residences distance from health centre (PR=0.795;95%CI=0.650-0.971;p=0.016), permission from their family (PR=0.675;95%CI=0.556-0.820;p=0.018), and being accompanied by their family (PR=0.824;95%CI=0.700-0.970;p=0.026). Age, marital status, occupation, and education background did not show a significant correlation with the women's decisions to receive cryotherapy.

CONCLUSIONS

Interestingly, the result of our study indicates that women are less willing to undergo the cryotherapy procedure if they have good knowledge about the cryotherapy procedure and its importance in cervical cancer's prevention. Providing higher quality and more accessible health facilities with cryotherapy services are important in influencing women's willingness to receive cryotherapy. Family support, in the form of permission given by spouses, and if they accompanied the patient to seek cryotherapy care are observed as factors influencing women's willingness to have the procedure.
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The contribution of Latin American research to HPV epidemiology and natural history knowledge

Our aim was to review the major contributions of studies conducted in different Latin American (LA) countries to the field of human papillomavirus (HPV) epidemiology, natural history, risk of disease, and prevention strategies, mainly in the uterine cervix. Although cytological screening is established in several countries in LA, incidence and mortality rates from cervical cancer (CC) are still extremely high. Finally, data from large cohort studies conducted in LA countries provided seminal data to propose primary and secondary prevention modalities: the HPV vaccine has been introduced in the national immunization programs of several LA countries and multiple screening experiences using HPV testing are under evaluation in the region.

A systematic review and meta-analysis of thermal coagulation compared with cryotherapy to treat precancerous cervical lesions in low- and middle-income countries

BACKGROUND

Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy.

OBJECTIVES

Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs.

SEARCH STRATEGY

Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010.

SELECTION CRITERIA

Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up.

DATA COLLECTION AND ANALYSIS

Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region.

MAIN RESULTS

Pooled cure proportions for cryotherapy and thermal coagulation, respectively, were 93.8% (95% CI, 88.5-97.7) and 91.4% (95% CI, 84.9-96.4) for CIN 1; 82.6% (95% CI, 77.4-87.3) and 91.6% (95% CI, 88.2-94.5) for CIN 2-3; and 92.8% (95% CI, 85.6-97.7) and 90.1% (95% CI, 87.0-92.8) for VIA-positive lesions. For thermal coagulation of CIN 2-3 lesions in LMICs 82.4% (95% CI, 75.4-88.6).

CONCLUSIONS

Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs.

Impact of antiviral AV2 in the topical treatment of HPV-associated lesions of the cervix: Results of a phase III randomized placebo-controlled trial

Background

Non-surgical topical therapies have been assessed in the treatment of precancerous lesions of the cervix. Their use can offer logistical and feasibility advantages in low-resource settings. Antiviral AV2^® is a mixture of natural essential oils (eugenol, carvone, nerolidol, geraniol) in olive oil, and has a broad spectrum anti-viral activity. In a phase II randomized controlled trial (RCT), AV2^® proved effective in reducing the size of cervical lesions associated with human papillomavirus (HPV). The purpose of the present study was to further evaluate the efficacy of AV2 over placebo in the topical treatment of HPV-associated cervical lesions.

Methods

Women aged 25 years and older were included in this phase 3 RCT. Cytology screening, HPV testing and visual inspection of the cervix with 5% acetic acid (VIA) were performed on all participants. VIA-positive women were randomized to one of two groups to receive treatment by either AV2® or placebo. The treatment consisted of 2 puffs of spray of the investigational drug directed to the cervix. Participants were subjected to repeat examinations two months and six months later for assessment of outcomes. The primary outcome was the change of lesions on VIA at 2 months after application of the investigational drug. Secondary outcomes were: HPV clearance and cytologic regression at 2 months and 6 months, and number of participants with AEs.

Results

A total 327 VIA positive women were randomized in two groups (168 in AV2 group and 159 in placebo group). Women in the 2 groups were similar with respect to baseline demographics and clinical characteristics. At 2 months, regression of lesions on VIA was observed in 127 (89.4%) out of 142 women in AV2 group compared to 120 (91.6%) out of 131 women in placebo group (P = 0.7). On cytology, regression of lesions occurred in 14 (56%) out of 25 women in the AV2 arm and in 13 (48.1) out of 27 women in the placebo arm (p = 0.7), and HPV clearance rates were 34.1% and 35% in AV2 group and placebo group respectively (p = 0.8). At 6 months cytologic regression was observed in 64.7% of women in AV2 group and 45.8% in placebo group (p = 0.2), while HPV clearance occurred in 11 (51.9%) out of 17 women in AV2 arm versus 11 (34.4%) in placebo arm (p = 0.3).

Some local side effects (burning, itching, irritation) were similarly noted in the 2 groups (p-values = 0.169, 0.623 and 0.172 respectively) but they were mild and transitory.

Conclusion

A topical application of AV2 onto the cervix can induce the regression of cervical precancerous lesions, but its efficacy does not significantly differ with that of placebo. The discrepancy between the expected and the recorded sample size as well as the huge number of lost to follow-up probably impeded the power of analyses, which could be one of the reasons for the lack of difference seen between AV2 and placebo. Further evaluation of the effects of AV2 with different diagnostic methods and treatment regimen and arms is warranted.

Clinical trial registration

NCT02346227 registered on November 8, 2014;

Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions

Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.

Depth of Cervical Intraepithelial Neoplasia Grade 3 in Peruvian Women: Implications for Therapeutic Depth of Necrosis

OBJECTIVE

To determine the involvement of cervical intraepithelial neoplasia grade 3 (CIN3) in a population of women in a lower-resource setting.

METHODS

One hundred twelve consecutive cone excision specimens with histological diagnosis of CIN3 were retrieved from the National Institute of Neoplastic Diseases in Lima Peru. Two pathologists independently evaluated each specimen microscopically and confirmed 107 cases that could be measured by optical micrometry. Depth and breadth of the lesions were measured microscopically.

RESULTS

The mean maximal depth of cervical involvement by CIN3 was 2 ± 0.13 mm; depth was less than 3.5 mm in 89.7% of cases and less than 5 mm in 93.5%. Mean breadth of CIN3 was 7.3 ± 4.4 mm; breadth was less than 15.9 mm in 95% of cases and less than 20.5 mm in 99.7%. The correlation coefficient between breadth and depth of CIN3 was 0.61. No significant correlation was found between age and depth.

CONCLUSIONS

Depth of CIN3 involvement in a developing country is significantly deeper than that reported in the United States. Treatment selection for women with CIN3 and risk of treatment failure may vary between developing and developed countries because of the difference in the depth of lesions. Countries with underscreened populations need to consider the increased disease severity in devising treatment strategies.

Management of cervical premalignant lesions

Treatment of cervical premalignant lesions (cervical intraepithelial neoplasia; CIN) of different grades is very effective, simple, and safe. The entire transformation zone of the cervix needs to be treated either by an ablative technique (cryotherapy or thermal ablation) or an excisional technique (large loop excision of transformation zone or cold knife conization); the choice of treatment depends on the size and location of the lesion and the type of the transformation zone. The cure rate after ablative treatment of high-grade CIN may be little lower than that after excisional treatment. The simplicity of the technique, low complication rate, and lesser cost make ablative technique the treatment of choice in the low resourced settings for the eligible lesions. In situations where organizing colposcopy and histopathology services is challenging, simple algorithms like screening with visual inspection with acetic acid test and immediate ablative treatment of the visual inspection with acetic acid-positive women has been recommended by the World Health Organization. Such a strategy is effective in preventing subsequent development of high-grade CIN and also ensures high compliance of the screen positive women to treatment.

Treatment of cervical intraepithelial lesions

Precancerous cervical lesions precede the development of invasive cervical cancer by 10-20 years, making cervical cancer preventable if these lesions are detected and effectively treated. Treatment has evolved in the last few decades and now includes ablative options that can be performed in lower-resource settings where surgical excision is not feasible or routinely available. Gas-based cryotherapy, which freezes cervical tissue to induce localized necrosis, is the most commonly used ablative treatment. However, its implementation in low-resource settings is difficult because the refrigerant gas can be difficult to procure and transport, and is expensive. New cryotherapy devices that do not require an external supply of gas appear promising. Thermal coagulation, which burns cervical tissue to induce necrosis, has become more widely available in the last few years owing to its portability and the feasibility of using battery-powered devices. These two ablative treatments successfully eradicate 75%-85% of high-grade cervical lesions and have minor adverse effects.

Difference Between Cryotherapy and Follow Up Low Grade Squamous Lesion of Cervix Uteri

INTRODUCTION

Cervical cancer can be successfully prevented by effective treatment.

AIM

Analyse of success of cryotherapy in LSIL and ASCUS.

MATERIALS ET METHODS

In retrospective study between January 2016 to March 2017, 3244 PAP test were analysed. 257 patients who had been diagnosed with LSIL and ASCUS from PAP smear were divided in two groups: women who had HPV positive, colposcopic positive and cytologic finding of LSIL or ASCUS treathed with cryotherapy and women with LSIL, ASCUS and negative colposcopy. χ2 test was used for statistical analysis of data.

RESULTS

Analysis of 3244 PAP smears showed negative for intraepithelial lesion or malignancy (NILM) in 90,10% (N-2923), and abnormal in 9,8% (N-321) of women. ASCUS was found in 4,8% (N-156) and ASC-H in 0,2% (N-6), LSIL in 3,1% (N-101), HSIL in 0,64% (N-21). The average age of patients with ASCUS lesion was 41 ± 12 years. After cryotherapy, HSIL had progression in 1,5% (N-1), persistence in 6,3% (N-4) and regression in 91,7% (N-58). Progression occured in 10,5% (N-4) of HSIL, persistence in 52,6% (N-20) and regression in 36,7% (N-14) in 38 women with LSIL lesion after repeated PAP test. Progression occured in 8% (N-10) of LSIL and 4% HSIL (N-5), persistence in 58% (N-72) and regression in 29,8% (N-37) in 124 women with ASCUS lesion after treatment and repeated PAP test. Difference in progression lesions in HSIL between women with cryotherapy (1,5%) and follow-up (10,5%) after LSIL is not significant, but progression to CIN II occured after cryotherapy. CIN III or cervical cancer was not found.

CONCLUSION

Cryotherapy prevents progression of LSIL in HSIL and in cervical cancer. Because of that cryotherapy is successful method in prevention of cervical cancer.

Management algorithms for cervical cancer screening and precancer treatment for resource-limited settings

Management algorithms for screen-positive women in cervical cancer prevention programs have undergone substantial changes in recent years. The WHO strongly recommends human papillomavirus (HPV) testing for primary screening, if affordable, or if not, then visual inspection with acetic acid (VIA), and promotes treatment directly following screening through the screen-and-treat approach (one or two clinic visits). While VIA-positive women can be offered immediate ablative treatment based on certain eligibility criteria, HPV-positive women need to undergo subsequent VIA to determine their eligibility. Simpler ablative methods of treatment such as cryotherapy and thermal coagulation have been demonstrated to be effective and to have excellent safety profiles, and these have become integral parts of new management algorithms. The challenges faced by low-resource countries are many and include, from the management perspective, identifying an affordable point-of-care HPV detection test, minimizing over-treatment, and installing an effective information system to ensure high compliance to treatment and follow-up.

Current Technologies and Recent Developments for Screening of HPV-Associated Cervical and Oropharyngeal Cancers

Mucosal infection by the human papillomavirus (HPV) is responsible for a growing number of malignancies, predominantly represented by cervical cancer and oropharyngeal squamous cell carcinoma. Because of the prevalence of the virus, persistence of infection, and long latency period, novel and low-cost methods are needed for effective population level screening and monitoring. We review established methods for screening of cervical and oral cancer as well as commercially-available techniques for detection of HPV DNA. We then describe the ongoing development of microfluidic nucleic acid-based biosensors to evaluate circulating host microRNAs that are produced in response to an oncogenic HPV infection. The goal is to develop an ideal screening platform that is low-cost, portable, and easy to use, with appropriate signal stability, sensitivity and specificity. Advances in technologies for sample lysis, pre-treatment and concentration, and multiplexed nucleic acid detection are provided. Continued development of these devices provides opportunities for cancer screening in low resource settings, for point-of-care diagnostics and self-screening, and for monitoring response to vaccination or surgical treatment.

Efficacy, safety, and acceptability of thermocoagulation for treatment of cervical intraepithelial neoplasia in a hospital setting in Brazil

OBJECTIVE

To analyze the acceptability, safety, and effectiveness of thermocoagulation for the treatment of histologically proven cervical intraepithelial neoplasia grade 2-3 (CIN2-3) lesions.

METHODS

In a retrospective study, data were obtained for women treated for CIN2-3 lesions by thermocoagulation at the Hospital de Clínicas de Porto Alegre, Brazil, between March 6, 2012, and October 29, 2013, and followed up after 1 year. The proportions of women with no evidence of disease, adverse effects, or complications were determined.

RESULTS

Among 52 women included, 44 (85%) had no evidence of disease 1year after thermocoagulation. The rate of no disease at follow-up was similar for women treated for CIN2 (17/20 [85%]) and CIN3 (27/32 [84%]). No serious adverse effects or complications requiring hospitalization were observed during the follow-up period.

CONCLUSION

Thermocoagulation is useful in the management of ectocervical CIN and should be integrated into public health services for management of cervical cancer.

Cervical Cancer Screening in the United States-Affiliated Pacific Islands: Options and Opportunities

OBJECTIVE

Successful cervical cancer screening in the United States-Affiliated Pacific Islands (USAPI) is limited by geographic, political, economic, and logistic factors. An expert panel convened to examine screening in each of the 6 island jurisdictions and to explore options beyond cytology-based screening.

MATERIALS AND METHODS

Forty-one representatives of American Congress of Obstetrics and Gynecology, American Society for Colposcopy and Cervical Pathology, government agencies, the World Health Organization, Pan American Health Organization, health representatives of the 6 Pacific island jurisdictions, Puerto Rico, and several academic institutions met in a 2-day meeting to explore options to improve access and coverage of cervical cancer screening in the USAPI.

RESULTS

Cytology-based screening is less widely accessed and less successful in the USAPI than in the United States in general. Barriers include geographic isolation, cultural factors, and lack of resources. Cytology-based screening requires multiple visits to complete the process from screening to treatment. Screen-and-treat regimens based on visual inspection with acetic acid or human papillomavirus requiring 1 or 2 visits have the potential to improve cervical cancer prevention in the USAPI.

CONCLUSIONS

The standard US algorithm of cytology screening followed by colposcopy and treatment is less effective in geographically and culturally isolated regions such as the USAPI. Alternate technologies, both high tech, such as primary human papillomavirus screening, and low tech, such as visual inspection with acetic acid, have shown promise in resource-poor countries and may have applicability in these US jurisdictions.

[Evaluation of results after treatment of cervical intraepithelial lesions by cryotherapy: a preliminary study at the University Hospital Centre in Yaounde: report of 21 cases]

Nous rapportons les résultats d'une série de 21 cas de prise en charge par cryothérapie de lésions intra-épithéliales cervicales au Centre Hospitalier et Universitaire (CHU) de Yaoundé. Notre objectif principal était d’évaluer les résultats préliminaires de la prise en charge des lésions précancéreuses éligibles pour la cryothérapie. Il s'agissait d'une étude transversale descriptive qui s'est étalée sur 24 mois. Etaient inclus dans l’étude toutes les femmes traitées par cryothérapie. Nous avons exclu les patientes traitées par une autre méthode, les patientes perdues de vue et les dossiers incomplets. Le statut cervical a été déterminé à 6 semaines, 6 mois et 12 mois. Les complications précoces et tardives ont également été répertoriées. Au total 95.2% des lésions étaient cicatrisées à 6 semaines. A 6 mois, toutes les lésions avaient disparu et au 12^ème mois, la guérison était effective chez 95.2% des patientes. Les saignements et l'hydrorrhée étaient les principales complications tardives avec des fréquences respectives de 66.7% et 95.2%. Aucun cas de sténose cervicale n'a été répertorié. La cryothérapie peut être utilisée comme méthode de traitement pour des lésions précancéreuses du col.

Knowledge, attitudes and practices regarding cervical cancer and screening among Haitian health care workers

It is estimated that Haiti has the highest incidence of cervical cancer in the Western Hemisphere. There are currently no sustainable and affordable cervical cancer screening programs in Haiti. The current status of screening services and knowledge of health care professionals was assessed through a Knowledge, Attitudes, and Practices survey on cervical cancer screening and prevention. It was distributed to Project Medishare for Haiti health care workers (n = 27) in the Central Plateau. The majority (22/27) of participants stated pre-cancerous cells could be detected through screening, however, only four had ever performed a pap smear. All of the participants felt a screening program should be started in their area. Our data establishes that knowledge is fairly lacking among healthcare workers and there is an opportunity to train them in simple, cost effective "screen-and-treat" programs that could have a great impact on the overall health of the population.

Current cervical cancer screening knowledge, awareness, and practices among U.S. affiliated pacific island providers: opportunities and challenges

BACKGROUND

Cervical cancer is a leading cause of cancer mortality in nearly all U.S. Affiliated Pacific Island Jurisdictions (USAPIJ); however, most jurisdictions are financially and geographically limited in their capacity to deliver routine screening.

METHODS

We conducted a cross-sectional survey of 72 health care providers from five of the six USAPIJ in 2011 to assess knowledge, beliefs, practices, and perceived barriers regarding routine cervical cancer screening. We compared the responses of providers from jurisdictions that were funded by the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with those that were not funded.

RESULTS

Most providers reported cervical cancer prevention as a priority in their clinical practices (90.3%) and use the Papanicolaou test for screening (86.1%). Many providers reported knowledge of screening guidelines (76.4%); however, more than half reported that annual screening is most effective (56.9%). Providers in non-NBCCEDP-funded jurisdictions reported greater acceptance of visual inspection with acetic acid (93.9%) and self-sampling for human papillomavirus testing (48.5%) compared with NBCCEDP-funded jurisdictions (15.4% and 30.8% respectively). Providers from non-NBCCEDP-funded jurisdictions reported inadequate technological resources for screening women (42.4%), and approximately 25% of providers in both groups believed that screening was cost-prohibitive.

CONCLUSION

Although cervical cancer screening is a priority in clinical practice, beliefs about annual screening, costs associated with screening, and varying levels of support for alternative screening tests pose barriers to providers throughout the USAPIJ. Further exploration of using evidence-based, lower cost, and sustainable screening technologies is warranted in addition to emphasizing timely follow-up of all positive cases.

Effectiveness of cryotherapy for histologically confirmed cervical intraepithelial neoplasia grades 1 and 2 in an Indian setting

OBJECTIVE

To describe the effectiveness of cryotherapy for treating women who were histologically confirmed to have cervical intraepithelial neoplasia (CIN) in India.

METHODS

Data were analyzed retrospectively from screening projects that collected data from January 2001 to May 2008 in Trivandrum, India. Women with CIN were appropriately treated with cryotherapy by a trained nurse or physician and followed up for cure, adverse events, and complications. Cure was defined as absence of CIN during any follow-up visit at least 1 year after treatment.

RESULTS

Among 236 women identified with CIN and appropriately treated with cryotherapy, 173 (81.6%) were followed up (158 CIN 1 and 15 CIN 2 cases). The percentage cure for CIN 1 and 2 lesions was 93.0% and 86.7% respectively. An odds ratio of 0.2 (95% confidence interval, 0.0-0.9) was observed for treatment received more than 2 months after screening as compared with treatment received within 2 months. Complications were observed in 1.2% of treated women and adverse events (discharge and mild pain) in 26.6%.

CONCLUSION

The study affirms that trained mid-level providers can appropriately perform cryotherapy in primary healthcare services and that expanding such services in low-resource settings would increase the availability and accessibility of precancer treatment.

Influencing women's actions on cervical cancer screening and treatment in Karawang District, Indonesia

INTRODUCTION

The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up.

METHODS

Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members.

RESULTS

Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.

Bolivian health providers' attitudes toward alternative technologies for cervical cancer prevention: a focus on visual inspection with acetic acid and cryotherapy

BACKGROUND

Little is known about health providers' attitudes toward visual inspection with acetic acid (VIA) and cryotherapy in the prevention of cervical cancer, as most research in Latin America and the Caribbean (LAC) has examined attitudes of the general population. This study describes attitudes of Bolivian health professionals toward new technologies for cervical cancer prevention, focusing on VIA and cryotherapy.

METHODS

Between February 2011 and March 2012, we surveyed 7 nurses and 35 physicians who participated in 5-day workshops on VIA and cryotherapy conducted in Bolivia. Multiple choice and open-ended questions were used to assess participants' acceptability of these procedures and the feasibility of their implementation in the context of perceived barriers for the early detection of cervical cancer in this country.

RESULTS

Most believed that cultural factors represent the main barrier for the early detection of cervical cancer (70%), although all stated that VIA and cryotherapy would be accepted by women, citing the advantages of VIA over cytology for this belief. Most also believed their colleagues would accept VIA and cryotherapy (71%) and that VIA should replace Pap testing (61%), reiterating the advantages of VIA for these beliefs. Those who believed the contrary expressed a general resistance to change associated with an already existing cytology program and national norms prioritizing Pap testing.

CONCLUSIONS

Most participants had favorable attitudes toward VIA and cryotherapy; however, a sizable minority cited challenges to their adoption by colleagues and believed VIA should not replace cytology. This report can inform the development of strategies to expand the use of alternative cervical cancer screening methods in LAC and Bolivia.

Low knowledge of cervical cancer and cervical pap smears among women in Peru, and their ideas of how this could be improved

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.

See-and-treat approaches to cervical cancer prevention for HIV-infected women

Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.

Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control

This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.

Human papillomavirus-based cervical cancer prevention: long-term results of a randomized screening trial

BACKGROUND

Screen-and-treat approaches to cervical cancer prevention are an attractive option for low-resource settings, but data on their long-term efficacy are lacking. We evaluated the efficacy of two screen-and-treat approaches through 36 months of follow-up in a randomized trial.

METHODS

A total of 6637 unscreened South African women aged 35-65 years who were tested for the presence of high-risk human papillomavirus (HPV) DNA in cervical samples underwent visual inspection of the cervix using acetic acid staining and HIV serotesting. Of these, 6555 were randomly assigned to three study arms: 1) HPV-and-treat, in which all women with a positive HPV DNA test result underwent cryotherapy; 2) visual inspection-and-treat, in which all women with a positive visual inspection test result underwent cryotherapy; or 3) control, in which further evaluation or treatment was delayed for 6 months. All women underwent colposcopy with biopsy at 6 months. All women who were HPV DNA- or visual inspection-positive at enrollment, and a subset of all other women had extended follow-up to 36 months (n = 3639) with yearly colposcopy. The endpoint-cervical intraepithelial neoplasia grade 2 or worse (CIN2+)-was analyzed using actuarial life-table methods. All statistical tests were two-sided.

RESULTS

After 36 months, there was a sustained statistically significant decrease in the cumulative detection of CIN2+ in the HPV-and-treat arm compared with the control arm (1.5% vs 5.6%, difference = 4.1%, 95% confidence interval [CI] = 2.8% to 5.3%, P < .001). The difference in the cumulative detection of CIN2+ in the visual inspection-and-treat arm compared with the control was less (3.8% vs 5.6%, difference = 1.8%, 95% CI = 0.4% to 3.2%, P = .002). Incident cases of CIN2+ (identified more than 12 months after enrollment) were less common in the HPV-and-treat arm (0.3%, 95% CI = 0.05% to 1.02%) than in the control (1.0%, 95% CI = 0.5% to 1.7%) or visual inspection-and-treat (1.3%, 95% CI = 0.8% to 2.1%) arms.

CONCLUSIONS

In this trial, a screen-and-treat approach using HPV DNA testing identified and treated prevalent cases of CIN2+ and appeared to reduce the number of incident cases of CIN2+ that developed more than 12 months after cryotherapy.

Treatment of high-grade squamous intraepithelial lesions in an area of Thailand with a high incidence of cervical cancer

OBJECTIVE

To audit the treatment of high-grade squamous intraepithelial lesions (HSILs) at Chiang Mai University Hospital based on 12 standard requirements of the National Health Service Cervical Screening Programme.

METHODS

Records were reviewed of all women with histologically proven HSIL undergoing treatment at Chiang Mai University Hospital between January 2005 and May 2009.

RESULTS

Four of the standard requirements were not met: not all women underwent colposcopy before definitive treatment; the rate of specimen fragmentation was high; among women with ectocervical lesions, the rate of tissue removal to a depth of greater than 7 mm was low; and among women aged over 50 years with endocervical-margin involvement, the rate of repeat excision was low.

CONCLUSION

This audit highlights four treatment practices that do not meet standard requirements and require detailed exploration. The development of guidelines for the treatment of cervical precancerous lesions in Thailand is challenging and merits further attention.

Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda

Background

There is scant information on whether Human Immunodeficiency Virus (HIV) seropositivity has an influence on the outcome of treatment of precancerous cervical lesions using cryotherapy. We studied the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to HIV serostatus and described the outcomes of cryotherapy treatment.

Methods

Trained nurses examined women not previously screened for cervical cancer using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) in two family planning/post natal clinics in Kampala, Uganda, from February 2007 to August 2008. Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with precancerous cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy.

Results

Of the 5 105 women screened, 834 presented a positive screening test and were referred for colposcopy. Of these 625 (75%) returned for the colposcopic evaluation and were tested for HIV. For the 608 (97.5%) women in the age range 20-60 years, colposcopy revealed 169 women with cervical lesions: 128 had inflammation, 19 had low grade squamous intraepithelial lesion (LGSIL), 13 had high grade squamous intraepithelial lesion (HGSIL), 9 had invasive cervical cancer and 2 had inconclusive findings. Detection rates per 1 000 women screened were higher among the older women (41-60 years) compared to women aged 20-40 years. They were accordingly 55% and 20% for inflammation, 10% and 2% for LGSIL, 5% and 2% for HGSIL, 6% and 1% for invasive cervical cancer.

Of the 608 women, 103 (16%) were HIV positive. HIV positivity was associated with higher likelihood of inflammation (RR = 1.7; 95% CI: 1.2-2.4).

Conclusions

Detection rates were higher among older women 41-60 years. Visual inspection of the cervix uteri with acetic acid (VIA) and Lugol's iodine (VILI) used as a sole method for cervical cancer screening would entail significant false positive results. HIV seropositivity was associated with a higher prevalence of inflammatory cervical lesions. In view of the small numbers and the relatively short follow up time of 3 months, we could not make an emphatic conclusion about the effect of HIV serostatus on cryotherapy treatment outcome.

Are treatments for cervical precancerous lesions in less-developed countries safe enough to promote scaling-up of cervical screening programs? A systematic review

Background

Since the mid-1990s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries.

Methods

We searched 12 databases (Medline, Google Scholar, Scopus, Cochrane Library, Web of Science, OCLC, PAIS International Database, WHO Global Health Library, CINAHL, Science.gov, NYAM Grey Literature Report, and POPLINE) for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median (minimum, maximum) reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed.

Results

The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment.

Conclusions

When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age.

Colposcopy audit for improving quality of service in areas with a high incidence of cervical cancer

OBJECTIVE

To audit routine colposcopy performance using 8 standard requirements of the National Health Service Cervical Screening Programme (NHSCSP).

METHODS

Records of women who underwent colposcopy for abnormal cervical cytology between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed.

RESULTS

The standard requirements were not achieved in 2 practices: (1) the proportion of women who had recordings of visibility of the transformation zone (96.6%) did not achieve the NHSCSP requirement of 100%; and (2) the rate of excisional biopsy (87.8%) was lower than the 95% minimum required.

CONCLUSION

Colposcopic performance at Chiang Mai University Hospital was generally favorable. However, re-audit is necessary to ensure that unmet standards of performance are improved and achieved standards are maintained.

The Mexican Cervical Cancer Screening Trial: self-sampling for human papillomavirus with unaided visual inspection as a secondary screen

The Mexican Cervical Cancer Screening (MECCS) study took place in the State of Michoacán. Primary screening was by self-sampling for high-risk human papillomavirus (HR-HPV). The objectives were to increase the specificity of primary HPV screening by requiring 2 positive HPV tests 1 year apart in women whose secondary screen was negative according to an acetic acid-aided visual inspection (VIA). In addition, we postulated that the sensitivity of VIA would be sufficient to identify large preinvasive lesions and cancers unsuitable for cryotherapy if applied in a see-and-treat algorithm.A total of 8621 women (aged 30-50 years) were screened, and 14.3% were positive for HR-HPV. In phase 1, 11.9% of the HPV-positive women were VIA-positive and were referred for colposcopy with directed and random biopsies. If VIA-negative, women repeated the self-sample 1 year later to detect persistent HR-HPV (25.2% were positive). If persistently HR-HPV-positive in phase 2, patients again had VIA, then all women (both VIA-positive and -negative) received directed and random biopsies. If cryotherapy had been used to treat HPV- and VIA-positive women in phase 1 or persistent HR-HPV-positive (phase 2), the potential risk of undertreatment would have been 4.1%, and 66.4% of the treated patients would have had normal or cervical intraepithelial neoplasia I on biopsy. The VIA triage would refer 0.73% of the patients to colposcopy owing to the lesion size, location, or the presence of a cancer. On the basis of this pilot study, we are encouraged to explore and evaluate a rapid, more sensitive, and more specific self-test.

New approaches to cervical cancer screening in Latin America and the Caribbean

Cervical cancer remains an important public health problem in the Latin America and Caribbean region (LAC), with an expected significant increase in disease burden in the next decades as a result of population ageing. Prophylactic human papillomavirus (HPV) vaccine is currently unaffordable in LAC countries. However, even if vaccination was implemented, an additional two decades will be required to observe its impact on HPV related disease and cancer. With some exceptions, cytology-based screening programs have been largely ineffective to control the problem in the region, and there is a need for new approaches to the organization of screening and for use of newly developed techniques. Several research groups in LAC have conducted research on new screening methods, some of which are summarized in this paper. A recommendation to reorganize screening programs is presented considering visual inspection for very low resource areas, improvement of cytology where it is operating successfully and HPV DNA testing followed by visual inspection with acetic acid (VIA) or cytology as soon as this method becomes technically and economically sustainable. This could be facilitated by the incorporation of new, low-cost HPV DNA testing methods and the use of self-collected vaginal specimens for selected groups of the population. An important requisite for screening based on HPV testing will be the quality assurance of the laboratory and the technique by validation and certification measures.