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Verma ML, Sharma P, Singh U, Sachan R, Sankhwar PL. Comparison of acceptability & efficacy of thermal ablation (thermocoagulation) & cryotherapy in VIA positive cervical lesions: A pilot study. Indian J Med Res 2023; 158:423-431. [PMID: 38006345 DOI: 10.4103/ijmr.ijmr_1166_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND OBJECTIVES The World Health Organization (WHO) has endorsed thermal ablation (thermocoagulation) as an efficient and safe modality for treatment of cervical pre-cancer lesions. More evidence is being looked up by WHO through rigorous studies for health delivery models using screen-and-treat strategies incorporating thermal ablation and studies comparing it against the conventional standard modality cryotherapy. The objective of this study was to assess the acceptability of thermal ablation both among the providers and clients and compare the same with cryotherapy. METHODS A randomized control trial was conducted for one year from September 2019 to October 2020 after obtaining ethics approval. Computer-generated random number table was used for randomization, and eligible candidates were divided into two groups following informed consent. Women with visual inspection with acetic acid (VIA) positive cervical lesions in Group A received cryotherapy and Group B received thermal ablation. After the procedure, the acceptability of the provider and the client were assessed using the International Agency for Research on Cancer-validated questionnaire for both the procedures. Immediate side effects and problems at six weeks and at six months were assessed as well. Efficacy was decided by the absence of VIA positivity at six months. RESULTS The overall VIA positivity in this study was 11.8 per cent. Thermal ablation (thermocoagulation) had better provision and client acceptability than cryotherapy (significant difference). The efficacy of thermal ablation was 97.6 per cent, while, it was 92 per cent for cryotherapy (not significant). INTERPRETATION CONCLUSIONS In the context of screen-and-treat programme in settings such as India, thermal ablation appears to be a better method of treatment than cryotherapy for cervical pre-cancerous lesions particularly in terms of better provision and client acceptability.
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Affiliation(s)
- Manju Lata Verma
- Department of Obstetrics & Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
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2
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Quang TT, Yang J, Mikhail AS, Wood BJ, Ramanujam N, Mueller JL. Locoregional Thermal and Chemical Tumor Ablation: Review of Clinical Applications and Potential Opportunities for Use in Low- and Middle-Income Countries. JCO Glob Oncol 2023; 9:e2300155. [PMID: 37625104 PMCID: PMC10581629 DOI: 10.1200/go.23.00155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/31/2023] [Accepted: 07/01/2023] [Indexed: 08/27/2023] Open
Abstract
This review highlights opportunities to develop accessible ablative therapies to reduce the cancer burden in LMICs.
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Affiliation(s)
- Tri T. Quang
- Department of Bioengineering, University of Maryland, College Park, MD
| | - Jeffrey Yang
- Department of Bioengineering, University of Maryland, College Park, MD
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Andrew S. Mikhail
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bradford J. Wood
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC
- Duke Global Health Institute, Duke University, Durham, NC
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC
| | - Jenna L. Mueller
- Department of Bioengineering, University of Maryland, College Park, MD
- Department of OB-GYN and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD
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3
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Gottschlich A, Payne BA, Trawin J, Albert A, Jeronimo J, Mitchell-Foster S, Mithani N, Namugosa R, Naguti P, Orem J, Rawat A, Simelela PN, Singer J, Smith LW, van Niekerk D, Nakisige C, Ogilvie G. Experiences with thermal ablation for cervical precancer treatment after self-collection HPV-based screening in the ASPIRE Mayuge randomized trial. Int J Cancer 2023; 152:1630-1639. [PMID: 36408923 DOI: 10.1002/ijc.34369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/04/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022]
Abstract
Cervical cancer remains a significant public health burden in low-resourced countries. Thus, the WHO prioritized cervix screening, and recently recommended thermal ablation treatment for cervical precancer. However, there is limited information on side effects during treatment and recovery, and acceptability among those treated. The ASPIRE Mayuge trial recruited women to participate in self-collection cervix screening between 2019 and 2020 (N = 2019). Screen-positive women (N = 531, 26.3%) were referred for visual inspection with acetic acid and thermal ablation treatment, per Uganda Ministry of Health recommendations; 71.2% of those referred attended follow-up. Six months post-screening, a subset of trial participants were recontacted. Those who received thermal ablation completed a survey assessing side effects during and after the procedure, and willingness to recommend the treatment to others. We summarized the results to describe the side effects and acceptability of thermal ablation treatment. Of 2019 participants, 349 (17%) received thermal ablation. A subset of 135 completed the follow-up survey, where 90% reported pain during treatment; however, intensity and duration were low. Over a third of women reported problems with recovery for reasons including pain, discharge and bleeding. Regardless, 98% reported they would recommend the treatment to others. The use of thermal ablation to treat cervical precancer appears to be highly acceptable in this population. While many women reported side effects during the procedure and recovery, the majority said they would recommend the treatment to others. However, given the substantial proportion who reported problems with recovery, efforts should be made to provide additional resources to women after receiving thermal ablation treatment for cervical precancer.
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Affiliation(s)
- Anna Gottschlich
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada.,University of British Columbia, Faculty of Medicine, Vancouver, Canada
| | - Beth A Payne
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada.,University of British Columbia, Faculty of Medicine, Vancouver, Canada
| | - Jessica Trawin
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada
| | - Arianne Albert
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada
| | | | - Sheona Mitchell-Foster
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada.,Northern Medical Program, University of British Columbia, Prince George, Canada
| | - Nadia Mithani
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada
| | | | | | | | - Angeli Rawat
- University of British Columbia, Faculty of Medicine, Vancouver, Canada
| | | | - Joel Singer
- University of British Columbia, Faculty of Medicine, Vancouver, Canada
| | - Laurie W Smith
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada.,BC Cancer Agency, Vancouver, Canada
| | - Dirk van Niekerk
- University of British Columbia, Faculty of Medicine, Vancouver, Canada.,BC Cancer Agency, Vancouver, Canada
| | | | - Gina Ogilvie
- BC Women's Hospital and Health Center, Women's Health Research Institute, Vancouver, Canada.,University of British Columbia, Faculty of Medicine, Vancouver, Canada
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4
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Balli C, Kenfack B, Horo A, Jeronimo J, Abatsong E, Wisniak A, Vassilakos P, Petignat P. Transformation Zone Assessment Using Visual Inspection With Acetic Acid Before and After Thermal Ablation: Implications for Follow-Up. JCO Glob Oncol 2023; 9:e2200241. [PMID: 36854076 PMCID: PMC10166473 DOI: 10.1200/go.22.00241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
PURPOSE Thermal ablation (TA) has become the conventional method for treatment of precancerous cervical lesions in low-resource settings. After TA, both the squamocolumnar junction (SCJ) and the transformation zone (TZ) may be subject to change. Our aim was to evaluate SCJ and TZ variability after TA. METHODS Study data were collected in a large prospective trial of a cervical cancer screening campaign in Cameroon. For each patient, two sets of cervical photos (native and with acetic acid) were taken before and 6-12 months after TA. The SCJ and TZ were evaluated independently by three observers according to the WHO nomenclature. When discordances were observed between the type of TZ and SCJ selected by each observer, a corrected TZ was established on the basis of the SCJ categorization. Interobserver agreement for TZ interpretation was evaluated using Cohen's kappa coefficient for agreement between two observers and Fleiss' kappa between three observers. RESULTS Fifty consecutive participants were included in the analysis. Seventy-six percent were interpreted as TZ1-2, and 24% as TZ3 before TA. In 56% of cases, the entire SCJ could not be entirely visualized after TA, thus being recategorized as TZ3. Interobserver agreement was fair for diagnosis before TA (Kappa coefficient, 0.34; 95% CI, 0.27 to 0.45) and moderate for diagnosis after TA (Kappa coefficient, 0.40; 95% CI, 0.30 to 0.50). After TA, 36% progressed from TZ1-2 to TZ3, with a moderate interobserver agreement (Kappa coefficient, 0.44; 95% CI, 0.40 to 0.54). CONCLUSION We observed a shift of the SCJ into the endocervical canal after TA. A significant proportion of participants had TZ 3 after treatment, raising the question of visual inspection with acetic acid's applicability as a first-line follow-up examination method after TA.
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Affiliation(s)
- Christine Balli
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Apollinaire Horo
- Unit of Gynecology and Obstetrics, University Hospital (CHU) of Yopougon, Abidjan, Ivory Coast
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Esther Abatsong
- Department of Biomedical Sciences, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Ania Wisniak
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Vassilakos
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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5
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Soler M, Alfaro K, Masch RJ, Conzuelo Rodriguez G, Qu X, Wu S, Sun J, Hernández Jovel DM, Bonilla J, Puentes LO, Murillo R, Alonzo TA, Felix JC, Castle P, Cremer M. Safety and Acceptability of Three Ablation Treatments for High-Grade Cervical Precancer: Early Data From a Randomized Noninferiority Clinical Trial. JCO Glob Oncol 2022; 8:e2200112. [PMID: 36525620 PMCID: PMC10166394 DOI: 10.1200/go.22.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE This ongoing trial is comparing the efficacy and safety of three ablation treatments for cervical intraepithelial neoplasia grade 2 or higher. Here, we present early data regarding pain, side effects, and acceptability of CO2 gas-based cryotherapy (CO2), nongas cryotherapy, and thermal ablation (TA). Efficacy results are expected to become available in late 2023. MATERIALS AND METHODS This noninferiority randomized trial is taking place in El Salvador, China, and Colombia. Patients are 1,152 eligible women with biopsy-confirmed cervical intraepithelial neoplasia grade 2 or higher who will receive one of three ablation treatments. Pain is measured before, during, and after treatment with a visual analog scale (1-10). Side effects and acceptability are assessed at 6 weeks. RESULTS To date, 1,024 of 1,152 (89%) women were randomly assigned to treatment. The median pain level was higher during TA (4, IQR = 4) than CO2 (2, IQR = 4) or nongas cryotherapy (2, IQR = 4) (P < .01, range: 0-10). The most common post-treatment symptom was watery discharge, reported by 97.9% of women, and it lasted longer in the CO2 group than the other two treatments (in days, median [IQR]: CO2 = 20[20], nongas cryotherapy = 15[10], TA = 18[15], P < .01). Bleeding was reported more frequently in women treated with TA (27.6%) than CO2 (17.5) or nongas cryotherapy (18.7%) (P < .01). The majority of patients reported being very satisfied with the treatment they received at 6 weeks (91%) and again at 12 months post-treatment (97%). CONCLUSION Despite differences in pain and side effects across ablation treatments, all were safe and highly acceptable to patients. In addition to efficacy, considerations such as cost and portability may be more significant in choosing a treatment method.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Karla Alfaro
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Rachel J Masch
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | | | - Xinfeng Qu
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Suhui Wu
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Jingfen Sun
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | | | - Jairo Bonilla
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Luis Orlando Puentes
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Raúl Murillo
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Todd A Alonzo
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Philip Castle
- Divisions of Cancer Prevention and Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
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6
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Morse RM, Brown J, Noble HE, Ríos López EJ, Kohler-Smith A, Soto S, Del Cuadro DL, Gonzales Díaz K, Figueredo Escudero M, Vásquez Del Aguila G, Carrillo Jara LE, Silva Delgado HF, Palacios VA, Santos-Ortiz C, Gravitt PE, Paz-Soldan VA. Women's perspectives on the acceptability and feasibility of an HPV screen-and-treat approach to cervical cancer prevention in Iquitos, Peru: a qualitative study. BMC Womens Health 2022; 22:414. [PMID: 36217187 PMCID: PMC9552409 DOI: 10.1186/s12905-022-01943-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The objective of this study was to explore women's experiences of a screen-and-treat approach with ablative therapy (referred to by the Spanish acronym TVT-TA) as a method of treatment following a positive HPV test in Iquitos, Peru. METHODS A total of 111 in-depth interviews were conducted with 47 HPV positive women who attended the TVT-TA procedure at a primary-level healthcare facility. Interviews were conducted immediately before, immediately after, and six-weeks after TVT-TA. RESULTS Most interviewed women reported experiencing moderate pain during ablative therapy and minimal pain immediately after and six weeks after ablative therapy. Women also stated that the pain was less intense than they had expected. The most common physical after-effects of treatment were bleeding and vaginal odor. Women experienced oscillating emotions with fear upon receiving a positive HPV result, calming after hearing about ablative therapy treatment, worry about pain from the treatment itself, relaxation with counseling about the procedure, and relief following treatment. CONCLUSIONS Nearly all participants emphasized that they were pleased with the TVT-TA process even if they had experienced pain during TVT-TA, recommended that TVT-TA be expanded and available to more women, and stated that TVT-TA was faster and easier than expected. This study found that TVT-TA is a feasible and acceptable means of treating HPV according to the women receiving the treatment.
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Affiliation(s)
- Rachel M Morse
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | - Helen E Noble
- Global Health Fogarty International Program, University of Washington Northern Pacific, Seattle, WA, USA
| | | | | | | | - Daniel Lenin Del Cuadro
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Karina Gonzales Díaz
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | - Magaly Figueredo Escudero
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Lita E Carrillo Jara
- Department of Cancer Control and Prevention, Gerencia Regional de Salud de Loreto, Iquitos, Loreto, Peru
| | | | - Victor A Palacios
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Carlos Santos-Ortiz
- Dirección de Prevención y Control de Cáncer, Ministerio de Salud, Lima, Peru
| | - Patti E Gravitt
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Valerie A Paz-Soldan
- Department of Tropical Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
- Asociación Benéfica PRISMA, Lima, Peru.
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7
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Piret EM, Payne BA, Smith LW, Trawin J, Orem J, Ogilvie G, Nakisige C. Side effects and acceptability measures for thermal ablation as a treatment for cervical precancer in low-income and middle-income countries: a systematic review and meta-synthesis. Fam Med Community Health 2022; 10:fmch-2021-001541. [PMID: 35523456 PMCID: PMC9083391 DOI: 10.1136/fmch-2021-001541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective Understanding the side effects and acceptability of thermal ablation (TA) is necessary before large-scale application in screen-and-treat programmes can be justified in low-income and middle-income countries (LMICs). Design Articles were selected for inclusion by two independent reviewers. Risk of bias was assessed using the Downs and Black’s criteria. Summary data were extracted, and authors contacted for data when necessary. Proportions of interest and 95% CIs were estimated using a random effects model. Subgroup analysis was performed based on place of treatment and timing of post-treatment follow-up. Heterogeneity was estimated using the I2. Eligibility criteria Studies that reported one or more side effects or patient acceptability measures after treatment of the cervix using TA in women living in LMICs who completed a cervical cancer screening test. Included articles were clinical trials or observational studies available in English and published before 18 December 2020. Information sources Ovid MEDLINE, EMBASE, CINAHL, CAB Global Health and WHO Global Index Medicus were searched for this systematic review and meta-synthesis. Results A total of 1590 abstracts were screened, 84 full text papers reviewed and 15 papers selected for inclusion in the qualitative review, 10 for meta-synthesis (N=2039). Significant heterogeneity was found in screening tests used to identify women eligible for TA and in methods to ascertain side effects. The most commonly reported side effect during treatment was pain (70%, 95% CI 52% to 85%; I2=98.01%) (8 studies; n=1454). No women discontinued treatment due to pain. At treatment follow-up, common side effects included vaginal discharge (72%, 95% CI 18% to 100%; I2=99.55%) (5 studies; n=771) and bleeding (38%, 95% CI 15% to 64%; I2=98.14%) (4 studies; n=856). Satisfaction with treatment was high in 99% (95% CI 98% to 100%; I2=0.00%) of women (3 studies; n=679). Conclusions TA results in a number of common side effects, though acceptability remains high among women treated in LMICs. Standardised side effect and acceptability reporting are needed as TA becomes more readily available. PROSPERO registration number CRD42020197605.
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Affiliation(s)
- Evelyne Marie Piret
- British Columbia Women's Hospital and Health Centre, Women's Health Research Institute, Vancouver, British Columbia, Canada.,Faculty of Medicine, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Beth A Payne
- British Columbia Women's Hospital and Health Centre, Women's Health Research Institute, Vancouver, British Columbia, Canada.,Faculty of Medicine, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurie W Smith
- British Columbia Women's Hospital and Health Centre, Women's Health Research Institute, Vancouver, British Columbia, Canada
| | - Jessica Trawin
- British Columbia Women's Hospital and Health Centre, Women's Health Research Institute, Vancouver, British Columbia, Canada
| | - Jackson Orem
- Department of Reproductive Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Gina Ogilvie
- British Columbia Women's Hospital and Health Centre, Women's Health Research Institute, Vancouver, British Columbia, Canada.,Faculty of Medicine, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Carolyn Nakisige
- Department of Reproductive Oncology, Uganda Cancer Institute, Kampala, Uganda
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8
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Metaxas T, Kenfack B, Sormani J, Tincho E, Lemoupa Makajio S, Wisniak A, Vassilakos P, Petignat P. Acceptability and safety of thermal ablation to prevent cervical cancer in sub-Saharan Africa. BMC Cancer 2022; 22:132. [PMID: 35109806 PMCID: PMC8812220 DOI: 10.1186/s12885-022-09202-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background The World Health Organization recommends thermal ablation as an alternative to cryotherapy to treat women with precancerous lesions in low-resource settings. However, limited data are available on women’s experience and adverse events (AEs) of the procedure in the context of Sub-Saharan Africa. The objective of this study was to evaluate the acceptability and safety of thermal ablation in women screened positive for precancerous cervical lesions. Methods Asymptomatic women aged 30–49 years old living in the Dschang Health District were invited to participate in a cervical cancer screening campaign termed “3 T-Approach” (for Test-Triage and Treat). Recruited women were asked to perform HPV self-sampling followed by triage with visual assessment and treatment with thermal ablation if required. After treatment and 4–6 weeks later, interviews were conducted to assess women’s experience on anxiety, discomfort, and pain during thermal ablation. AEs were recorded on pre-defined electronic forms 4–6 weeks after treatment to assess the procedure’s safety. Results Between September 2018 and December 2020, 399 HPV-positive women (18.7% of women screened) were recruited, 236 (59.1%) had a positive visual assessment, 234 were treated by thermal ablation and 198 (84.6%) received therapy in the same visit. Treatment was not considered as painful (score ≤ 4/10) by 209 (90.9%) patients while 5 (2.5%) reported high pain (score 8–10/10). During post-treatment interviews 4–6 weeks later, most reported AEs were graded mild or moderate (grade I-II). The most frequent symptoms reported as mild AEs (grade 1–2) were vaginal watery discharge (75.5%), vaginal bloody-stained discharge (21.5%) and malodourous discharge (14.5%). None of the participants experienced serious AEs (grade 3–4) or AEs requiring admission to hospital or emergency consultation. The vast majority of women (99.6%) would agree to repeat the procedure if necessary and (99.6%) would recommend it to friends or family. Conclusion Thermal ablation is widely accepted by women and appears as a safe procedure. It may contribute to improving the link between screening and treatment in a single visit and to optimizing cervical cancer control in low-resource settings. Trial registration The study was registered on clinicaltrials.gov (NCT03757299) in November 2018 (28/11/2018).
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Affiliation(s)
- Tania Metaxas
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland.
| | - Bruno Kenfack
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Jessica Sormani
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland.,School of Health Sciences Geneva, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Eveline Tincho
- Faculty of Medicine and Biomedical Sciences, University Teaching Hospital of Yaounde, Yaounde, Cameroon
| | - Sophie Lemoupa Makajio
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
| | - Ania Wisniak
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
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9
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Soler M, Masch R, Saidu R, Cremer M. Thermal Ablation Treatment for Cervical Precancer (Cervical Intraepithelial Neoplasia Grade 2 or Higher [CIN2+]). Methods Mol Biol 2022; 2394:867-882. [PMID: 35094363 DOI: 10.1007/978-1-0716-1811-0_46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cervical cancer is a leading cause of mortality for women in low- and middle-income countries (LMICs). Invasive disease can be prevented through the treatment of high-grade cervical precancer lesions. Types of treatment for cervical precancer include excisional procedures that surgically remove the affected tissue and ablation treatments which utilize extreme temperatures to destroy precancerous cells. Excision is the first-line treatment in higher income countries, but requires specialized training and equipment that make it unsuitable for low-income settings. The most common treatment globally is cryotherapy, which utilizes cryogenic gas to freeze the area. However, the need for gas presents significant procurement and logistical challenges. The World Health Organization (WHO) has recently endorsed the use of thermal ablation, a method that utilizes heat to destroy precancerous tissue. This review describes three existing thermal ablation devices and protocols for their use, including step-by-step instruction guides to perform a successful treatment with each device and observations specific to each machine.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
- Basic Health International, Pittsburgh, PA, USA.
| | | | - Rakiya Saidu
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, Pittsburgh, PA, USA
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10
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Klyn LL, Chapola J, Mapanje C, Bula A, Tang JH, Gopal S, Chome N, Phiri B, Chinula L. Lessons learned from a rural, community-based cervical cancer screen-and-treat pilot study in Malawi. PUBLIC HEALTH IN PRACTICE 2021; 2:100110. [PMID: 36101585 PMCID: PMC9461538 DOI: 10.1016/j.puhip.2021.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Invasive cervical cancer (ICC) is the leading cause of cancer-related death among women in Malawi. Barriers to screening for ICC in Malawi, such as long distances to health facilities and lack of public education about ICC, have hindered participation of women in ICC prevention programs. Given the burden of disease and barriers to screening, we implemented a community-based ICC screen-and-treat pilot study and present its successes and challenges. Study design This study was a screen-and-treat pilot study using Visual Inspection with Acetic acid (VIA) for screening and same-day thermal ablation for treatment of pre-cancerous lesions. The pilot was implemented in four rural community settings in Lilongwe District, Malawi. Methods With consultation from local leaders, as well as the UNC Project-Malawi Community Department and the Community Advisory Board, a team of researchers designed a rural, community-based ICC screen-and-treat pilot study. Over a 5-week period, we travelled to four rural communities to provide information about and screening for ICC and HIV through our study. The four selected rural locations were about an hour drive from Lilongwe City, Malawi. Detailed field notes were taken by study staff and then later analyzed and categorized as either strengths or challenges. Results Successes included support from local leaders, high uptake of screening (408 women underwent VIA, representing 88% of eligible women), positive experiences during screening, and good communication between study staff and participants. This communication enabled us to quickly address misperceptions about the study intent and procedures and to better understand some of the barriers to care. Challenges included insufficient medication for diagnosed sexually transmitted infections, finding ways to engage interested women who were ineligible due to young age, and not screening interested women because they needed male partner approval. Conclusion Community-based screen-and-treat programs with thermal ablation for ICC can be an effective way to engage hard-to-reach women in ICC preventive care. Our findings support existing literature which suggests that involvement of local leadership, women from the community, and their male partners, as well as ongoing peer education, may facilitate greater participation in ICC screening and treatment. In addition, we found ongoing communication between study staff and participants to be mutually beneficial. Finally, we suggest that future interventions consider bundling sexually transmitted infection treatment into ICC preventive care when engaging hard-to-reach populations.
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Affiliation(s)
- Laura Limarzi Klyn
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Corresponding author. UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | - John Chapola
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Clement Mapanje
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Agatha Bula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jennifer H. Tang
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
- Department of Obstetrics and Gynecology, University of Malawi, College of Medicine, Malawi
| | - Satish Gopal
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Nelecy Chome
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Billy Phiri
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Lameck Chinula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
- Department of Obstetrics and Gynecology, University of Malawi, College of Medicine, Malawi
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11
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Ribeiro A, Corrêa F, Migowski A, Leal A, Martins S, Raiol T, Marques CP, Torres KL, Novetsky AP, Marcus JZ, Wentzensen N, Schiffman M, Rodriguez AC, Gage JC. Rethinking Cervical Cancer Screening in Brazil Post COVID-19: A Global Opportunity to Adopt Higher Impact Strategies. Cancer Prev Res (Phila) 2021; 14:919-926. [PMID: 34607876 DOI: 10.1158/1940-6207.capr-21-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/05/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022]
Abstract
The World Health Organization global call to eliminate cervical cancer encourages countries to consider introducing or improving cervical cancer screening programs. Brazil's Unified Health System (SUS) is among the world's largest public health systems offering free cytology testing, follow-up colposcopy, and treatment. Yet, health care networks across the country have unequal infrastructure, human resources, equipment, and supplies resulting in uneven program performance and large disparities in cervical cancer incidence and mortality. An effective screening program needs multiple strategies feasible for each community's reality, facilitating coverage and follow-up adherence. Prioritizing those at highest risk with tests that better stratify risk will limit inefficiencies, improving program impact across different resource settings. Highly sensitive human papillomavirus (HPV)-DNA testing performs better than cytology and, with self-collection closer to homes and workplaces, improves access, even in remote regions. Molecular triage strategies like HPV genotyping can identify from the same self-collected sample, those at highest risk requiring follow-up. If proven acceptable, affordable, cost-effective, and efficient in the Brazilian context, these strategies would increase coverage while removing the need for speculum exams for routine screening and reducing follow-up visits. SUS could implement a nationwide organized program that accommodates heterogenous settings across Brazil, informing a variety of screening programs worldwide.
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Affiliation(s)
- Ana Ribeiro
- Department of Pharmacy, Faculty of Health Sciences, University of Brasília (UNB), Brasília, District Federal, Brazil. .,Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Flávia Corrêa
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Arn Migowski
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Brazil
| | - Aline Leal
- General Coordination of Specialized Care, Health Care Secretariat, Ministry of Health (MS), Brasília, District Federal, Brazil
| | - Sandro Martins
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Tainá Raiol
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil
| | - Carla P Marques
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil.,Department of Public Health, Faculty of Ceilândia, University of Brasília (UNB), Brasília, District Federal, Brazil
| | - Katia L Torres
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (FIOCRUZ), Brasília, District Federal, Brazil.,Amazon State Oncology Control Foundation (FCECON), Manaus, Amazonas, Brazil
| | - Akiva P Novetsky
- Rutgers New Jersey Medical School (NJMS), Newark, New Jersey.,Rutgers Cancer Institute of New Jersey (CINJ), New Brunswick, New Jersey
| | - Jenna Z Marcus
- Rutgers New Jersey Medical School (NJMS), Newark, New Jersey
| | - Nicolas Wentzensen
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Mark Schiffman
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Ana Cecilia Rodriguez
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
| | - Julia C Gage
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland
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12
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Mungo C, Osongo CO, Ambaka J, Randa MA, Omoto J, Cohen CR, Huchko M. Safety and Acceptability of Thermal Ablation for Treatment of Human Papillomavirus Among Women Living With HIV in Western Kenya. JCO Glob Oncol 2021; 6:1024-1033. [PMID: 32634066 PMCID: PMC7392781 DOI: 10.1200/go.20.00035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The WHO now recommends thermal ablation as an alternative to cryotherapy within “screen-and-treat” cervical cancer programs in low- and middle-income countries (LMICs). We conducted a safety and acceptability clinical trial of thermal ablation in a Kenyan Ministry of Health hospital among women living with HIV (WLWH; ClinicalTrials.gov identifier: NCT04191967). METHODS Between August 2019 and February 2020, WLWH age 25-65 years underwent human papillomavirus (HPV) self-collection in western Kenya. HPV-positive women underwent visual inspection with acetic acid, biopsy, and treatment with thermal ablation performed by a nonphysician clinician, if eligible by standard guidelines. A questionnaire was administered after treatment to assess for pain and treatment acceptability. Adverse events (AEs) were evaluated 4-6 weeks after treatment with a standardized grading tool. RESULTS A total of 293 HPV-positive WLWH underwent thermal ablation in the study period. The mean age was 40.4 years (standard deviation, 8.7 years). After treatment, 15 (5.1%), 231 (78.8%), 42 (14.3%), and 5 (1.8%) reported none, mild, moderate, and severe pain with treatment, respectively. At follow-up, spotting, vaginal discharge, and pelvic pain were reported by 99 (37.8%), 258 (98.5%), and 46 (17.6%), respectively, for a median of 3.3 (interquartile range [IQR], 2-3), 14 (IQR, 7-21), and 7 (IQR, 3-7) days, respectively. Most participants graded their AEs as mild (grade 1): 94 (95.0%) for bleeding, 125 (48.5%) for vaginal discharge, and 37 (80.4%) for pelvic pain. No grade 3 or 4 AEs were reported. The vast majority (99.2%) were satisfied with the treatment and would recommend it to a friend. CONCLUSION Thermal ablation performed by nonphysicians in the public health sector in Kenya proved safe and highly acceptable in treating HPV-positive WLWH.
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Affiliation(s)
- Chemtai Mungo
- Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA
| | | | | | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Megan Huchko
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
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13
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Shin MB, Liu G, Mugo N, Garcia PJ, Rao DW, Bayer CJ, Eckert LO, Pinder LF, Wasserheit JN, Barnabas RV. A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities. Front Public Health 2021; 9:670032. [PMID: 34277540 PMCID: PMC8281011 DOI: 10.3389/fpubh.2021.670032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022] Open
Abstract
The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.
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Affiliation(s)
- Michelle B. Shin
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Gui Liu
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patricia J. Garcia
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Cayetano Heredia University, Lima, Peru
| | - Darcy W. Rao
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Cara J. Bayer
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Linda O. Eckert
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Leeya F. Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Judith N. Wasserheit
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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14
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Kakani P, Kojima N, Banda BA, Lewis S, Suri R, Chibwana F, Chivwara M, Sullivan L, Chimombo M, Sigauke H, Tymchuk C, Kahn D. Increasing cervical cancer screening at a non-government medical center in Lilongwe, Malawi. Int J STD AIDS 2021; 32:933-939. [PMID: 33910402 DOI: 10.1177/09564624211007260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malawi has the highest incidence of and mortality rate due to cervical cancer in the world. This is largely because of inadequate screening and high rates of human immunodeficiency virus (HIV) infection, which greatly increases cervical cancer risk. We describe the implementation of a quality improvement program to increase use of cervical cancer screening at a non-government medical center in Lilongwe, Malawi. The intervention, developed and launched from March to August 2017, aimed to promote education among patients and clinicians about the importance of cervical cancer screening and improve accessibility of screening information within medical records. Visual inspection with acetic acid (VIA) was used to screen for cervical cancer. Women with a positive VIA were offered treatment using thermocoagulation. The number of VIA screenings conducted in 2016 (pre-intervention), 2017 (intervention), and 2018 (post-intervention) was 125, 234 and 456, respectively. Of the 815 women screened during this period, 36 (4.4%) had a VIA-positive result and 12 (1.5%) had suspect cancer. Of the VIA-positive women, 13 (36.1%) received same-day treatment with thermocoagulation. An interrupted time series regression revealed that there was a sustained increase in monthly screenings between the pre- and post-intervention period (β = 30.84; p = 0.006; 95% CI 9.72-51.97), suggesting that the intervention likely was effective in increasing cervical cancer screening. Our results demonstrate that focusing on developing sustainable solutions and improving system processes, without additional equipment or funding, significantly increased the number of women screened and should be considered in other settings to enhance cervical cancer prevention services.
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Affiliation(s)
- Preeti Kakani
- 12222David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Noah Kojima
- Department of Internal Medicine, 12222University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Samuel Lewis
- 12222David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Rajat Suri
- Department of Internal Medicine, 12222University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | - Lauren Sullivan
- Department of Internal Medicine, 12222University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | - Chris Tymchuk
- Department of Internal Medicine, 12222University of California at Los Angeles, Los Angeles, CA, USA
| | - Daniel Kahn
- Department of Internal Medicine, 12222University of California at Los Angeles, Los Angeles, CA, USA
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15
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Zhao XL, Liu ZH, Zhao S, Hu SY, Muwonge R, Duan XZ, Du LJ, Su CF, Xiang XE, Zhang X, Pan QJ, Qiao YL, Sankaranarayanan R, Zhao FH, Basu P. Efficacy of point-of-care thermal ablation among high-risk human papillomavirus positive women in China. Int J Cancer 2021; 148:1419-1427. [PMID: 32895912 DOI: 10.1002/ijc.33290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023]
Abstract
Thermal ablation is a point-of-care ablative treatment technique for cervical intraepithelial neoplasia (CIN). However, limited information is available about its efficacy in low- and middle-income countries. We evaluated the efficacy of thermal ablation in treatment of CIN detected through high-risk human papillomavirus (HPV) screening in China. Women positive on high-risk HPV and having colposcopically suspected lesions eligible for ablation underwent colposcopy, biopsy and thermal ablation in one visit. Women ineligible were recalled for large loop excision of transformation zone (LLETZ) when histopathology results were high-grade CIN. Posttreatment follow-up at 6 months or more was with HPV test and cytology followed by colposcopy and biopsy for HPV and/or cytology-positive women. Cure was defined as either negative cytology and HPV test or absence of histopathology proved CIN in any positive women. Of total 218 HPV-positive women treated with thermal ablation (n = 170) or LLETZ (n = 48), 196 reported for follow-up evaluation. For women with histologically confirmed CIN at baseline (thermal ablation-104; LLETZ-38), cure rates were 84.6% for thermal ablation and 86.8% for LLETZ. Cure rates after thermal ablation were 90.3% for CIN grade one (CIN1) and 76.2% for CIN grade two or worse (CIN2+). HPV clearance rate was 80.4% in women undergoing thermal ablation, which was lower for HPV16/18 compared to other oncogenic types (67.6% vs 85.7%). HPV test had a negative predictive value (NPV) of 98.7% to detect CIN2+ at follow-up and the positive predictive value (PPV) was 40.4%. Thermal ablation is effective to treat CIN as well as to clear the high-risk HPV infection. HPV test has high PPV and NPV in following up patients posttreatment.
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Affiliation(s)
- Xue-Lian Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hua Liu
- Department of Gynecology, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Shaung Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shang-Ying Hu
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Xian-Zhi Duan
- Department of Obstetrics and Gynecology, Beijing Tongren Hospital, Beijing, China
| | - Li-Jun Du
- Department of Obstetrics and Gynecology, Erdos Maternal and Child Health Care Hospital, Erdos, Inner Mongolia, China
| | - Cai-Feng Su
- Department of Gynecology, Xiangyuan Maternal and Child Health Care Hospital, Changzhi, Shanxi, China
| | - Xi-E Xiang
- Department of Gynecology, Xiangyuan Maternal and Child Health Care Hospital, Changzhi, Shanxi, China
| | - Xun Zhang
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin-Jing Pan
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - You-Lin Qiao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rengaswamy Sankaranarayanan
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
- Senior Medical Advisor, RTI (Research Triangle Institute) International, New Delhi, India
| | - Fang-Hui Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
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16
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Binagwaho A, Garcia PJ, Gueye B, Dykens JA, Simelela N, Torode J, Goba G, Bosland MC. Eliminating Deaths From Cervical Cancer-Report of a Panel at the 7th Annual Symposium on Global Cancer Research, a Satellite Meeting at the Consortium of Universities for Global Health 10th Annual Meeting. J Glob Oncol 2020; 5:1-7. [PMID: 31774712 PMCID: PMC6882512 DOI: 10.1200/jgo.19.00287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
This is a summary of the presentations addressing approaches and achievements to reach the goal of eliminating cervical cancer as a global public health problem that were delivered at the 7th Annual Symposium on Global Cancer Research at the 10th Annual Consortium of Universities for Global Health Meeting in March 2019. Dr Princess Nothemba Simelela, Assistant Director-General for Family, Women, Children and Adolescents, World Health Organization, gave an introduction to the World Health Organization-led Cervical Cancer Elimination Initiative and the emerging conceptual framework and targets that will shape the global 2020 to 2030 strategy. Subsequent presentations shared experiences from national programs in Rwanda (Agnes Binagwaho), Latin America (Patricia J. Garcia), and Senegal (Babacar Gueye and J. Andrew Dykens. Successes in intensified human papillomavirus vaccination and screening with follow-up treatment of early and advanced lesions detected are highlighted as well as the challenges and obstacles in achieving and maintaining high coverage in Africa and Latin America. With strong political leadership, commitment of national stakeholders, and the use of proven and cost-effective approaches to human papillomavirus vaccination, screening, and treatment, the vision of a world free of cervical cancer and saving women's lives every year by preventing deaths from cervical cancer will be achievable in the next generation in all countries.
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Affiliation(s)
- Agnes Binagwaho
- University of Global Health Equity, Butaro, Rwanda.,Harvard Medical School, Boston, MA
| | - Patricia J Garcia
- Cayetano Heredia University, Lima, Peru.,University of Washington, Seattle, WA
| | - Babacar Gueye
- Senegal Ministry of Health and Social Action, Dakar, Senegal
| | | | | | - Julie Torode
- Union for International Cancer Control, Geneva, Switzerland
| | - Gelila Goba
- University of Illinois at Chicago, Chicago, IL
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17
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Banerjee D, Mandal R, Mandal A, Ghosh I, Mittal S, Muwonge R, Lucas E, Basu P. A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting. Asian Pac J Cancer Prev 2020; 21:1391-1398. [PMID: 32458647 PMCID: PMC7541890 DOI: 10.31557/apjcp.2020.21.5.1391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The prospective randomized study aimed to compare the safety, acceptability and efficacy of thermal ablation (TA) to that of cryotherapy in screen and treat setting. METHODS The participants were recruited prospectively in a community-based screening clinic in India. Women positive on visual inspection with acetic acid (VIA) test and/or Human Papillomavirus (HPV) test were assessed for eligibility for ablative treatment. Total 286 eligible women were randomized to receive either cryotherapy (N=150) or TA (N=136) performed by health workers. Colposcopy and cervical biopsy were performed on all, prior to treatment. Post-treatment follow-up was after one year with colposcopy and biopsy. RESULTS Both the treatment methods had high acceptability. Significantly higher proportion of women treated by cryotherapy reported pain compared to women treated by TA, though intensity was mild in vast majority of them. Approximately 30% of women in both arms had histologic abnormalities, mainly CIN 1, and among those who attended follow-up 74.1% and 81.0% didn't have any CIN after cryotherapy and TA respectively. CONCLUSION TA is as acceptable and safe as cryotherapy in screen and treat setting. TA has the logistic advantages for the low-resourced settings as the machines are more portable, do not require costly refrigerant gas and battery-driven models are available. The cure rates for CIN 1+ lesions in our study were comparable between cryotherapy and TA.
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Affiliation(s)
| | - Ranajit Mandal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Amit Mandal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Ishita Ghosh
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Srabani Mittal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | | | - Eric Lucas
- International Agency for Research on Cancer, Lyon, France.
| | - Partha Basu
- International Agency for Research on Cancer, Lyon, France.
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18
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Sandoval M, Slavkovsky R, Bansil P, Jeronimo J, Lim J, Figueroa J, de Sanjose S. Acceptability and safety of thermal ablation for the treatment of precancerous cervical lesions in Honduras. Trop Med Int Health 2019; 24:1391-1399. [PMID: 31622526 PMCID: PMC6916631 DOI: 10.1111/tmi.13315] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective To evaluate the acceptability and safety of thermal ablation (TA) for the treatment of precancerous cervical lesions in women in Honduras. Methods Human papillomavirus (HPV) and visual inspection with acetic acid (VIA) screen‐positive eligible women received TA. After treatment, women rated the level of pain experienced during treatment using the Wong‐Baker FACES® pain‐rating scale from 0 to 10. Short‐term safety outcomes that could require medical attention were assessed one month after treatment. Results A total of 319 women received TA treatment. The average pain rating was 2.5 (95% CI: 2.3–2.8), and 85% rated their pain levels as less than 6. No significant differences in low (below 6) or high (6 and above) pain were found by age or number of biopsies performed, but there was a significant difference by the number of TA applications (P < 0.01). When asked if they would recommend this treatment, all women said they would. At the one‐month follow‐up visit, the most common reported discomforts were bleeding (10%) and cramping (8.4%); 11 women reported severe lower abdominal pain, and none required medical attention. Conclusions TA is safe and acceptable to patients as a treatment option for precancerous cervical lesions in low‐resource settings.
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Affiliation(s)
- Manuel Sandoval
- Asociación Hondureña de Planificación de Familia, Tegucigalpa, Honduras
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Cremer ML, Conzuelo-Rodriguez G, Cherniak W, Randall T. Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions. J Glob Oncol 2019; 4:1-10. [PMID: 30372399 PMCID: PMC7010451 DOI: 10.1200/jgo.18.00093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.
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Affiliation(s)
- Miriam L Cremer
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Gabriel Conzuelo-Rodriguez
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - William Cherniak
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Thomas Randall
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
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20
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Selmouni F, Belakhel L, Sauvaget C, Abousselham L, Lucas E, Muwonge R, Sankaranarayanan R, Khazraji YC, Basu P. Evaluation of the national cervical cancer screening program in Morocco: achievements and challenges. J Med Screen 2019; 26:162-168. [PMID: 30651034 DOI: 10.1177/0969141318824627] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
Objectives To report the key outcomes of evaluation of the national cervical cancer screening program in Morocco, and describe its organization, status of implementation, performance, and major challenges. Methods An evaluation team conducted program manager interviews and screening provider focus group discussions, supervisory visits to primary health and diagnostic centers, and review of published documents. Aggregated performance data collected by the Ministry of Health from the screening and diagnostic centers were analyzed. Results Screening is conducted using visual inspection with acetic acid. The program is opportunistic, with no mechanism to identify and invite eligible women. Coverage of the target population was very low (6.6% in 2015 and 7.7% in 2016). Positivity rates were 5.3% and 8.9% in 2015 and 2016 respectively, and varied widely between regions. Detection rate of cervical intraepithelial neoplasia (CIN) 2 or worse in 2016 was very low (0.9/1,000), with more invasive cancers detected than CIN 2/3. Lack of histopathology and treatment facilities at the Cancer Early Detection Centers is a major short-coming, and there is a need for service-provider refresher training. Without a computerized health information system tracking screen positive women, ensuring high treatment compliance and performing regular quality assurance are challenging. Conclusions The screening program in Morocco requires better organization, a pragmatic system of inviting the target population, improved compliance to diagnosis, treatment, and follow-up, improved provider training, better quality assurance systems, and an effective health information system with appropriate linkages for monitoring and evaluation.
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Affiliation(s)
- Farida Selmouni
- 1 Screening Group, International Agency for Research on Cancer, Lyon, France
| | - Latifa Belakhel
- 2 Department of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco
| | - Catherine Sauvaget
- 1 Screening Group, International Agency for Research on Cancer, Lyon, France
| | | | - Eric Lucas
- 1 Screening Group, International Agency for Research on Cancer, Lyon, France
| | - Richard Muwonge
- 1 Screening Group, International Agency for Research on Cancer, Lyon, France
| | - Rengaswamy Sankaranarayanan
- 4 Research Triangle Institute International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India
| | | | - Partha Basu
- 1 Screening Group, International Agency for Research on Cancer, Lyon, France
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21
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de Fouw M, Oosting RM, Rutgrink A, Dekkers OM, Peters AAW, Beltman JJ. A systematic review and meta-analysis of thermal coagulation compared with cryotherapy to treat precancerous cervical lesions in low- and middle-income countries. Int J Gynaecol Obstet 2019; 147:4-18. [PMID: 31273785 DOI: 10.1002/ijgo.12904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 05/09/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Marlieke de Fouw
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Roos Marieke Oosting
- Department of BioMechanical Engineering, Delft University of Technology, Delft, Netherlands
| | - Amy Rutgrink
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Olaf Matthijs Dekkers
- Department of Clinical Epidemiology and Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jogchum Jan Beltman
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
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22
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Cremer M, Alfaro K, Garai J, Salinas M, Maza M, Zevallos A, Taxa L, Diaz AC, Castle P, Alonzo TA, Masch R, Soler M, Conzuelo-Rodriguez G, Gage JC, Felix JC. Evaluation of two alternative ablation treatments for cervical pre-cancer against standard gas-based cryotherapy: a randomized non-inferiority study. Int J Gynecol Cancer 2019; 29:ijgc-2018-000148. [PMID: 31055452 PMCID: PMC9884482 DOI: 10.1136/ijgc-2018-000148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/20/2019] [Accepted: 04/08/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Gas-based cryotherapy is the conventional ablative treatment for cervical pre-cancer in low-income settings, but the use of gas poses significant challenges. We compared the depth of necrosis induced by gas-based cryotherapy with two gas-free alternatives: cryotherapy using CryoPen,and thermoablation. METHODS We conducted a five-arm randomized non-inferiority trial: double-freeze carbon dioxide (CO2) cryotherapy (referent), single-freeze CO2 cryotherapy, double-freeze CryoPen, single-freeze CryoPen, and thermoablation. Subjects were 130 women scheduled for hysterectomy for indications other than cervical pathology, and thus with healthy cervical tissue available for histological evaluation of depth of necrosis post-surgery. The null hypothesis was rejected (ie, conclude non-inferiority) if the upper bound of the 90% confidence interval (90% CI) for the difference in mean depth of necrosis (referent minus each experimental method) was <1.14 mm. Patient pain during treatment was reported on a scale of 0 (no pain) to 10 (worst pain). RESULTS A total of 133 patients were enrolled in the study. The slides from three women were deemed unreadable. One patient was excluded because her hysterectomy was postponed for reasons unrelated to the study, and two patients were excluded because treatment application did not follow the established protocol. For the remaining 127 women, mean depth of necrosis for double-freeze CO2 (referent) was 6.0±1.6 mm. Differences between this and other methods were: single-freeze CO2 = 0.4 mm (90% CI -0.4 to 1.2 mm), double-freeze CryoPen= 0.7 mm (90% CI 0.04 to 1.4 mm), single-freeze CryoPen= 0.5 mm (90% CI -0.2 to 1.2 mm), and thermoablation = 2.6 mm (90% CI 2.0 to 3.1 mm). Mean pain levels were 2.2±1.0 (double-freeze CO2 cryotherapy), 1.8±0.8 (single-freeze CO2 cryotherapy), 2.5±1.4 (double-freeze CryoPen), 2.6±1.4 (single-freeze CryoPen), and 4.1±2.3 (thermoablation). DISCUSSION Compared with the referent, non-inferiority could not be concluded for other methods. Mean pain scores were low for all treatments. Depth of necrosis is a surrogate for treatment efficacy, but a randomized clinical trial is necessary to establish true cure rates.
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Affiliation(s)
- Miriam Cremer
- OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Basic Health International, San Salvador, El Salvador
- Basic Health International, New York City, New York, USA
| | - Karla Alfaro
- Basic Health International, San Salvador, El Salvador
| | - Jillian Garai
- Basic Health International, New York City, New York, USA
| | - Manuel Salinas
- Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador
| | - Mauricio Maza
- Basic Health International, San Salvador, El Salvador
| | | | - Luis Taxa
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Ana C Diaz
- Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador
| | - Philip Castle
- Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Todd A Alonzo
- University of Southern California, Los Angeles, California, USA
| | - Rachel Masch
- Basic Health International, New York City, New York, USA
| | - Montserrat Soler
- OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Basic Health International, New York City, New York, USA
| | | | - Julia C Gage
- National Cancer Institute, Bethesda, Maryland, USA
| | - Juan C Felix
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Randall TC, Sauvaget C, Muwonge R, Trimble EL, Jeronimo J. 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. Prev Med 2019; 118:81-91. [PMID: 30342109 DOI: 10.1016/j.ypmed.2018.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Thomas C Randall
- Gynecologic Oncology, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Edward L Trimble
- Global HPV and Cervical Cancer Research and Control, National Cancer Institute, Rockville, MD, USA
| | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Seattle, WA, USA
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Tran PL, Kenfack B, Tincho Foguem E, Viviano M, Temogne L, Tebeu PM, Catarino R, Benski AC, Vassilakos P, Petignat P. Efficacy of thermoablation in treating cervical precancerous lesions in a low-resource setting. Int J Womens Health 2017; 9:879-886. [PMID: 29238232 PMCID: PMC5716313 DOI: 10.2147/ijwh.s142911] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Treating cervical intraepithelial neoplasia (CIN) grades 2 and 3 is the recommended strategy for preventing invasive carcinoma in low- and middle-income countries (LMICs). Our objective was to assess the efficacy of thermoablation in the treatment of CIN2 and CIN3 in a screen-and-treat approach. Methods Women aged 30-49 years in Dschang, Cameroon, were invited to undergo vaginal sampling for human papillomavirus (HPV), samples being assessed by an Xpert HPV Assay. HPV-positive women underwent visual inspection with acetic acid (VIA) and visual inspection with Lugol's iodine (VILI), cervical biopsy, and endocervical curettage. Women positive for HPV-16/18/45 or other HPV types with abnormal VIA/VILI were treated by thermoablation on the same day. The primary outcome was persistence of high-grade disease on cytologic examination at 12 months. Results Of a total of 1,012 recruited women, 188 were HPV-positive, 121 patients required thermoablation, and 99 had a CIN of grade <2, making the overtreatment rate 9.9%. The cure rate for CIN2 and CIN3 at 12 months was 70.6%. Failure (higher risk of persistent disease) was associated with the presence of occult endocervical lesions at baseline diagnosis (adjusted odds ratio [aOR] =128.97 [95% confidence interval [CI], 8.80-1,890.95]; p<0.0001). First sexual intercourse before the age of 15 was also a risk factor (aOR =0.003 [95% CI, 0.001-0.61]; p=0.023). Conclusion In LMICs, use of thermoablation in a screen-and-treat approach is a valuable treatment option for CIN2 and CIN3. Studies comparing thermoablation with cryotherapy are needed to determine the most appropriate treatment for cervical precancer in such countries.
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Affiliation(s)
- Phuong Lien Tran
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | - Eveline Tincho Foguem
- Department of Gynecology and Obstetrics, District Hospital of Biyem-Assi, Yaoundé, Cameroon
| | - Manuela Viviano
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Liliane Temogne
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | - Pierre-Marie Tebeu
- Department of Gynecology and Obstetrics, University Centre Hospital, Yaoundé, Cameroon
| | - Rosa Catarino
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Anne-Caroline Benski
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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25
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Haney K, Tandon P, Divi R, Ossandon MR, Baker H, Pearlman PC. The Role of Affordable, Point-of-Care Technologies for Cancer Care in Low- and Middle-Income Countries: A Review and Commentary. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2017; 5:2800514. [PMID: 29204328 PMCID: PMC5706528 DOI: 10.1109/jtehm.2017.2761764] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/06/2017] [Indexed: 12/22/2022]
Abstract
As the burden of non-communicable diseases such as cancer continues to rise in low- and middle-income countries (LMICs), it is essential to identify and invest in promising solutions for cancer control and treatment. Point-of-care technologies (POCTs) have played critical roles in curbing infectious disease epidemics in both high- and low-income settings, and their successes can serve as a model for transforming cancer care in LMICs, where access to traditional clinical resources is often limited. The versatility, cost-effectiveness, and simplicity of POCTs warrant attention for their potential to revolutionize cancer detection, diagnosis, and treatment. This paper reviews the landscape of affordable POCTs for cancer care in LMICs with a focus on imaging tools, in vitro diagnostics, and treatment technologies and aspires to encourage innovation and further investment in this space.
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Affiliation(s)
- Karen Haney
- Dell Medical SchoolThe University of Texas at Austin
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Castle PE, Murokora D, Perez C, Alvarez M, Quek SC, Campbell C. Treatment of cervical intraepithelial lesions. Int J Gynaecol Obstet 2017; 138 Suppl 1:20-25. [PMID: 28691333 DOI: 10.1002/ijgo.12191] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
| | - Dan Murokora
- Uganda Women's Health Initiative, Kampala, Uganda
| | | | - Manuel Alvarez
- Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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Campos NG, Tsu V, Jeronimo J, Mvundura M, Kim JJ. Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med 2017; 6:2008-2014. [PMID: 28707435 PMCID: PMC5548874 DOI: 10.1002/cam4.1123] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/25/2017] [Indexed: 01/25/2023] Open
Abstract
Women in developing countries disproportionately bear the burden of cervical cancer. The availability of prophylactic vaccines against human papillomavirus (HPV) types 16 and 18, which cause approximately 70% of cervical cancers, provides reason for optimism as roll-out begins with support from Gavi, the Vaccine Alliance. However, for the hundreds of millions of women beyond the target age for HPV vaccination, cervical cancer screening to detect and treat precancerous lesions remains the only form of prevention. Here we describe the challenges that confront screening programs in low-resource settings, including (1) optimizing screening test effectiveness; (2) achieving high screening coverage of the target population; and (3) managing screen-positive women. For each of these challenges, we summarize the tradeoffs between resource utilization and programmatic attributes. We then highlight opportunities for efficient and equitable programming, with supporting evidence from recent mathematical modeling analyses informed by data from the PATH demonstration projects in India, Nicaragua, and Uganda.
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Affiliation(s)
- Nicole G. Campos
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
| | - Vivien Tsu
- PATHReproductive Health ProgramSeattleWashington
| | | | | | - Jane J. Kim
- Center for Health Decision ScienceHarvard T.H. Chan School of Public Health718 Huntington AvenueBostonMassachusetts
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