Cervical cancer screening guidelines and screening practices in 11 countries: A systematic literature review

Women's knowledge, attitude, and practice regarding cervical precancerous lesions: a cross-sectional study in Beijing, China

Background

This study aimed to examine the knowledge, attitude, and practice (KAP) of women in Beijing regarding cervical precancerous lesions.

Methods

This web-based, cross-sectional study included women at Dongzhimen Hospital of Beijing University of Chinese Medicine between March 13, 2024 and April 9, 2024. A self-administered questionnaire was developed to collect participants' demographic information and KAP scores toward cervical precancerous lesions.

Results

The study included 951 valid questionnaires, with a mean age of 40.0 years. The mean knowledge, attitude, and practice scores were 12.55 ± 6.23 (possible range: 0-26), 50.66 ± 7.48 (possible range: 13-65), and 26.13 ± 4.98 (possible range: 7-35), respectively. The knowledge score (OR = 1.071, 95%CI: 1.040-1.103, p < 0.001), currently married (OR = 0.548, 95%CI: 0.304-0.985, p = 0.045), and with a history of HPV infection (OR = 2.302, 95%CI: 1.062-4.990, p = 0.035) were independently associated with the attitude score. The knowledge score (OR = 1.155, 95%CI: 1.119-1.192, p < 0.001), monthly income >20,000 (OR = 2.793, 95%CI: 1.249-6.248, p = 0.012), a history of HPV infection (OR = 0.380, 95%CI: 0.222-0.650, p < 0.001), unknown HPV infection status (OR = 0.289, OR = 0.177-0.473, p < 0.001), vaccinated against HPV (OR = 1.752, 95%CI: 1.221-2.514, p = 0.002), giving birth to one child (OR = 1.991, 95%CI: 1.186-3.341, p = 0.009), and giving birth to two or more children (OR = 2.160, 95%CI: 1.240-3.763, p = 0.007) were independently associated with the practice score. The structured equation model showed that knowledge directly influenced attitude (β = 0.237, p = 0.004) and practice (β = 0.490, p = 0.010). Attitude directly influenced practice (β = 0.193, p = 0.009).

Conclusion

This study revealed inadequate knowledge, moderate attitude, and practice toward cervical precancerous lesions among women in Beijing. Educational interventions should be developed to enhance knowledge in this regard.

Implementation of WHO guidelines for cervical cancer screening, diagnosis and treatment: knowledge and perceptions of health providers from Argentina

BACKGROUND

The 2021 World Health Organization (WHO) guidelines on cervical cancer screening and treatment provide countries with evidence-based recommendations to accelerate disease elimination. However, evidence shows that health providers' adherence to screening guidelines is low. We conducted a study in Argentina to analyze health providers' knowledge and perceptions regarding the 2021 WHO Guidelines.

METHODS

A qualitative study was conducted based on individual, semi-structured interviews with health providers specializing in gynecology (n = 15). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

Although health providers perceive WHO as a reliable institution, they do not know the 2021 guidelines, its supporting evidence, and its elaboration process. Their clinical practice is mainly guided by local recommendations developed by national professional medical associations (PMAs). For interviewees, WHO guidelines should be disseminated through health authorities and national PMAs, mainly through in-service training. Health providers had a positive assessment regarding WHO Recommendation 1 (screen, triage, and treatment for women aged 30 + with HPV-testing every 5 to 10 years) and perceived a favorable climate for its implementation. HPV-testing followed by triage was considered a low-complexity practice, enabling a better detection of HPV, a better selection of the patients who will need diagnosis and treatment, and a more efficient use of health system resources. However, they suggested adapting this recommendation by removing screening interval beyond 5 years. WHO Recommendation 2 (screen-and-treat approach with HPV-testing for women aged 30 + every 5 to 10 years) was predominantly rejected by interviewees, was considered an algorithm that did not respond to women's needs, and was not adequate for the Argentinean context. Regarding the HPV-test modality, clinician-collected tests were the preferred mode. Health providers considered that HPV self-collection should be used primarily among socially vulnerable women to increase screening coverage.

CONCLUSION

WHO guidelines should be widely disseminated among health providers, especially in settings that could benefit from a screen-and-treat approach. Identifying areas of partnership and collaboration with PMAs in implementing WHO guidelines is essential.

Implementation strategies of cervical cancer screening in South Asia: A systematic review

BACKGROUND

Cervical cancer is a preventable cancer by screening, vaccination and timely management of preinvasive cervical lesions. However, about 90% of the global burden of cervical cancer is reported from developing countries.

OBJECTIVE

This systematic review aimed to analyze the strategies implemented for cervical cancer screening in South Asia.

SEARCH STRATEGY

An electronic search of PubMed/MEDLINE, Scopus and Google Scholar was carried out for articles published in English, evaluating the implementation of cervical cancer screening between December 2000 and June 2023 in South Asia using appropriate search terms.

SELECTION CRITERIA

Cross-sectional studies, randomized control trials (RCTs) or non-randomized controlled trials evaluating different cervical screening strategies were included.

DATA COLLECTION AND ANALYSIS

A three-stage selection process was performed using a validated proforma including the title, author, year of publication, objective, country, study design, screening methods, strategies and outcomes, and results. The systematic review was designed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias was evaluated with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools.

MAIN RESULTS

Out of the initial 1135 articles reviewed systematically, 23 studies met the inclusion criteria and were included in the qualitative synthesis of results. The implementation outcomes measured were acceptability (n = 23 100%), feasibility (n = 22, 95.7%), fidelity (n = 14, 60.9%), sustainability (n = 7, 30.4%), coverage (n = 4, 17.4%) and cost (n = 1, 4.3%).

CONCLUSION

Cervical cancer screening can be effectively implemented by restructuring the ongoing programs.

Cervical cancer screening by cytology and the burden of epithelial abnormalities in low resource settings: a tertiary-center 42-year study

BACKGROUND

Cytological screening remains a high-impact practice, particularly in low-resource settings, for preventing cervical cancer. The examination of screening practices over time and the prevalence of epithelial abnormalities have not been investigated in longitudinal studies in one of the largest countries in the Middle East and Africa.

METHODS

Routine healthcare data, between March 1981 and December 2022, were extracted from the database of the Early Cancer Detection Unit in a tertiary referral university hospital in the Greater Cairo Region, Egypt. Cervical smears were obtained using a standardized technique and sent to the cytopathology laboratory for conventional cytology examination by expert pathologists. The anonymous data were analyzed to determine the temporal trend of the number of women screened each year and the prevalence of epithelial abnormalities.

RESULTS

Data included the results of satisfactory smears from 95120 women. The mean age (SD) of the women at the time of screening was 38.5 (10.5). None of the included women received an HPV vaccine. Abnormal epithelial cells were reported in 5174 women (5.44%). Of these epithelial abnormalities, the majority were low-grade squamous intraepithelial lesions in 4144 women (4.36%). Other abnormalities included atypical squamous cells in 378 women (0.40%), high-grade squamous intraepithelial lesions in 226 women (0.24%), atypical glandular cells not otherwise specified in 184 women (0.19%), adenocarcinoma in 165 women (0.17%), squamous cell carcinoma in 70 women (0.07%), and atypical glandular cells favoring neoplasms in 7 women (0.01%). Women who were at an early age at first intercourse, those who opted for routine cervical cytology screening, and those who were older at screening were more likely to have epithelial abnormalities. The yearly number of screened women was positively associated with the detection of low-grade squamous intraepithelial lesions (correlation coefficient [95% CI] = 0.84 [0.72, 0.91]) and negatively associated with the detection of squamous cell carcinoma (correlation coefficient [95% CI] = -0.55 [-0.73, -0.29]).

CONCLUSIONS

The small number of annually screened Egyptian women and the temporal trend in epithelial abnormalities critically demonstrate the need for establishing and scaling up a structured population-based program to achieve the goal of eliminating cervical cancer.

Attitudes toward the American Cancer Society's 2020 cervical cancer screening guidelines: A qualitative study of a national sample of US clinicians

BACKGROUND

The 2020 American Cancer Society (ACS) guidelines are the most recent national guidelines for cervical cancer screening. These guidelines propose two major changes from current practice: initiating screening at age 25 years and using primary human papillomavirus (HPV) testing. Adoption of guidelines often occurs slowly, and therefore understanding clinician attitudes is important to facilitate practice change.

METHODS

Interviews with a national sample of clinicians who perform cervical cancer screening in a variety of settings explored attitudes toward the two major changes from the 2020 ACS cervical cancer screening guidelines. Clinicians participated in 30- to 60-min interviews exploring their attitudes toward various aspects of cervical cancer screening. Qualitative analysis was performed.

RESULTS

Seventy clinicians participated from across the United States. Few respondents were initiating screening at age 25 years, and none were using primary HPV testing. However, over half would be willing to adopt these practices if supported by scientific evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional societies, lack of laboratory availability and insurance coverage, limited autonomy within large health care systems, and concerns related to missed disease.

CONCLUSIONS

Few clinicians have adopted screening initiation or primary HPV testing, as recommended by the 2020 ACS guidelines, but over half were open to adopting these changes. Implementation may be facilitated via professional organization endorsement, clinician education, and laboratory, health care system, and insurance support.

PLAIN LANGUAGE SUMMARY

In 2020, the American Cancer Society (ACS) released updated guidelines for cervical cancer screening. The main changes to current practices were to initiate screening at age 25 years instead of age 21 years and to screen using primary human papillomavirus (HPV) testing rather than cytology alone or in combination with HPV testing. We performed in-depth interviews with 70 obstetrics and gynecology, family medicine, and internal medicine physicians and advanced practice providers about their attitudes toward these guidelines. Few clinicians are following the 2020 ACS guidelines, but over half were open to changing practice if the changes were supported by evidence and recommended by professional medical organizations. Barriers to adoption included the lack of endorsement by professional medical organizations, logistical issues, and concerns about missed disease.

Human papillomavirus infection among adolescents living with HIV: a focus on prevention

PURPOSE OF REVIEW

To highlight recent data on HPV infection and cervical precancerous lesions in adolescents with HIV, and priorities for primary and secondary HPV prevention.

RECENT FINDINGS

Incident and persistent high-risk HPV infections and cervical abnormalities are higher among young women with perinatally acquired HIV compared to their HIV-negative peers; data on HPV among males with perinatally acquired HIV are scarce. HPV vaccination is highly effective in preventing HPV-related disease, but antibody titers may decline in people with HIV. It remains unclear if emerging recommendations to reduce vaccine schedules from three doses to two or one dose are appropriate for children and adolescents with perinatally acquired HIV. Due to higher risks of HPV-related cancers, screening guidelines for cervical cancer differ in their frequency and age at initiation for women with HIV, but there are no recommendations for women with perinatally acquired HIV; nor for anal cancer screening for men with perinatally acquired HIV.

SUMMARY

Data on the effectiveness of reduced HPV vaccine schedules in children and adolescents with HIV are needed. Implementation research to guide strategies for vaccination, screening, and treatment should include children, adolescents, and young adults with perinatally acquired HIV to ensure they are not left behind.

Clinical Outcomes and Molecular Predictors of Pembrolizumab (Keytruda) as a PD-1 Immune Checkpoint Inhibitor in Advanced and Metastatic Cervical Cancer: A Systematic Review and Meta-Analysis

This systematic review evaluates the clinical outcomes and molecular predictors of response to pembrolizumab in patients with advanced and metastatic cervical cancer. We adhered to the PRISMA guidelines for systematic reviews, conducting a database search in PubMed, Scopus, and Embase. The eligibility criteria centered on clinical outcomes, including the overall survival (OS), progression-free survival (PFS), and immune-related biomarkers post-pembrolizumab therapy. We included both prospective and retrospective studies that detailed clinical outcomes and molecular characteristics predictive of therapeutic response. Our search yielded six studies involving 846 patients treated with pembrolizumab from 2017 to 2022. The meta-analysis of these studies showed that pembrolizumab, used as monotherapy or in combination with chemotherapy, extended the OS by a weighted median of 10.35 months and the PFS by 8.50 months. The treatment demonstrated a pooled objective response rate (ORR) of 22.39%, although the I2 test result of 67.49% showed a high heterogeneity among the studies. Notably, patients with high PD-L1 expression (CPS ≥ 10) experienced improved outcomes in terms of the PFS and OS. The most common complications were fatigue, diarrhea, and immune-related adverse events. Pembrolizumab significantly enhances clinical outcomes in metastatic cervical cancer, particularly among patients with high PD-L1 expression. The drug maintains a good safety profile, reinforcing its treatment potential for patients with advanced and metastatic cervical cancer. Future studies should explore long-term effects and strategies to integrate pembrolizumab optimally into current treatment regimens, aiming to maximize patient benefits and effectively manage side effects.

Principles for Service Delivery: Best Practices for Cervical Screening for Women with Disabilities

Background

Cervical cancer screening is an important public health priority, yet many marginalized groups are not reached by existing programs. The nearly 700 million women with disabilities globally face substantial barriers in accessing cervical cancer screening and have lower coverage, yet there is limited evidence on what would support enhanced uptake among this population.

Methods

We updated a systematic review to estimate the disparity in screening uptake for women with disabilities. We conducted a scoping review to understand key barriers and the inclusion of disability in existing screening policies and possible solutions to improve screening uptakes amongst women with disabilities. We then formulated key principles for improved service delivery for this group, targeted predominantly at clinicians.

Results

Our updated review identified an additional five new studies, and confirmed that women with disabilities were less likely to be screened for cervical cancer (RR=0.65, 0.50-0.84). Disability-specific barriers to accessing screening pertained to: (1) knowledge and autonomy; (2) logistics; and (3) stigma and fear. Few guidelines included specific considerations for women with disabilities. Our scoping review showed that improving access to care must focus on improving (1) autonomy, awareness, and affordability; (2) human resources; and (3) health facility accessibility.

Conclusion

Screening programmes and health providers must ensure women with disabilities are included in cervical cancer screening programmes and thereby help to achieve their right to health and eliminate cervical cancer as a public health issue.

Awareness Level of Cervical Cancer Patients Referred to Radiation Oncology Outpatient Clinics-A Multicenter Study

OBJECTIVE

The study aimed to assess the level of knowledge of patients with cervical cancer referred to radiation oncology outpatient clinics in Turkey regarding screening methods and human papillomavirus (HPV) vaccination and increase social awareness based on the findings.

METHODS

A descriptive cross-sectional survey was conducted from January to June 2022 involving 300 patients in various regions. Data on demographics, cervical cancer screening and HPV vaccination knowledge, and recommendations to relatives were collected through a questionnaire-based interview. Univariate logistic regression analyzed the impact of independent variables on knowledge levels.

RESULTS

Among the participants, 57% were unaware of cervical cancer screening, and 66% had no knowledge of the HPV vaccine. Higher knowledge levels were associated with higher education, older age at marriage and first birth, and previous gynecological checkups. Lower knowledge levels were observed in patients treated at state institutions, with no formal education, and diagnosed with cervical cancer at age 60 or older. A significant inverse correlation was found between knowledge levels and the stage of cancer at diagnosis, with higher awareness in earlier stages.

CONCLUSION

The study revealed limited awareness among cervical cancer patients in Turkey regarding screening and HPV vaccination. Lower knowledge levels were associated with specific demographic factors, emphasizing the importance of targeted educational campaigns to reduce the burden of cervical cancer and promote early detection. Efforts to enhance vaccination coverage and encourage early screening can significantly improve outcomes. Comprehensive awareness surveys are essential in guiding policymaking and implementing effective early detection and prevention strategies for cervical cancer.

Interventions to Increase Cancer Screening Adherence Among Somali Immigrants in the US and Europe: A Systematic Review

Cancer screening rates among immigrant and refugee populations in high income countries is significantly lower than native born populations. The objective of this study is to systematically review the effectiveness of interventions to improve screening adherence for breast, cervical and colorectal cancer among Somali immigrants. A literature search was conducted for the years 2000-2021 and eight studies met eligibility criteria. The following intervention components were found to increase adherence to cervical cancer screening: home HPV test, educational workshop for women and education for general practitioners. A patient navigator intervention was found to increase screening for breast cancer. Educational workshops motivated or increased knowledge regarding cancer screening for breast, cervical and colorectal cancer. However, most of the studies had limitations due to methodology with potential for introduction of bias. Therefore, future studies comparing effectiveness of specific intervention components to reduce disparities in cancer screening among Somali immigrants and refugees are encouraged.

Current status and challenges in timely detection of cervical cancer in Mexico: expert consensus

Cervical cancer is a significant public health problem in low- and middle-income countries, accounting for 85% of new cases worldwide. Due to poorly organized screening programs, cervical cancer is more likely to develop in vulnerable groups who do not initiate or rarely undergo screening. Cervical cytology and detecting high-risk human papillomavirus types are the recommended screening tools. Further, these strategies allow for accurately identifying women at a higher risk of cervical cancer and establishing screening times. New detection tools, such as novel biomarkers or automatic HPV detection in the vagina or urine, can improve screening coverage. This review aims to identify the challenges faced by detection programs and screening tools in Mexico to provide evidence-based recommendations to improve early detection programs for cervical cancer.

Correlation between P16/Ki67 in cervical cytology and diagnosis of cervical intraepithelial neoplasia 2-3 in Thai women infected with high-risk types of human papillomavirus

OBJECTIVES

The addition of p16/Ki-67 dual immunostaining to human papilloma virus (HPV) screening tests has been shown to increase the detection rate of high-grade cervical intraepithelial neoplasia. Thus, the aim of this study was to evaluate the accuracy of p16/Ki67 dual staining in the detection of cervical intraepithelial neoplasia 2 (CIN2+) in women with high-risk HPV infection.

MATERIALS AND METHODS

A cross-sectional study was conducted between August 2017 and August 2019 at the Chulabhorn Hospital in Bangkok, Thailand. Women aged 20-70 years who underwent co-testing and tested positive for high-risk (HR) HPV (N = 215) were invited to participate in the study. P16/Ki67 testing was performed on residual cytological materials. Colposcopic biopsies were performed on all patients, and the results were correlated with positive or negative p16/Ki-67 test results.

RESULTS

The sensitivity and specificity of p16/Ki-67 dual staining in the detection of CIN2+ in the women with HR HPV infection were 74.4 % and 63.4 %, respectively. Compared with liquid-based cytology (LBC), p16/Ki67 cytology had similar sensitivity (p = 1.000) and specificity (p = 0.561) to LBC for detecting CIN2+.

CONCLUSION

In this study, p16/Ki67 dual staining in HPV triage demonstrated a test performance similar to that of LBC.

Cancer screening research in Bangladesh: Insights from a scoping review

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

Are HPV-negative lesions concerned for the introduction of primary HPV testing for cervical cancer screening in Japan?

AIM

In Japan, primary human papilloma virus (HPV) testing has not been introduced for cervical cancer screening due to concerns that HPV-negative lesions may be missed and a lack of Japanese data. The purpose of this study was to evaluate the validity of primary HPV testing in Japan by analyzing cervical intraepithelial neoplasia 2 (CIN2) or more/high-risk HPV- (CIN2+/hrHPV-) cases in cervical cancer screening.

METHODS

Data from 35 525 cervical cancer screenings with HPV testing and cervical cytology from 2011 to 2019 in Saga City, Japan, were reviewed. The cases with low-grade squamous intraepithelial lesion (LSIL+)/hrHPV- were analyzed in detail.

RESULTS

The results of the 35 525 examinees were as follows: 31 123 were negative for intraepithelial lesion or malignancy (NILM)/hrHPV-, 2612 were NILM/hrHPV+, 262 were atypical squamous cells of undetermined significance (ASC-US)/hrHPV-, 213 were ASC-US/hrHPV+, 291 were LSIL+/hrHPV-, and 1024 were LSIL+/hrHPV+. Of the 256 LSIL+/hrHPV- examinees for whom histology was available, CIN2+ were CIN2 9.4% (24/256), CIN3 3.9% (10/256), cervical adenocarcinoma 0.4% (1/256), uterine corpus cancer 1.2% (3/256), and uterine sarcoma 0.4% (1/256). Overall, the rate of LSIL+/hrHPV- was 0.82% (291/35.525), 0.1% (36/35525) of which were cervical lesions with CIN2+. Only one cervical adenocarcinoma was detected, but gastric-type adenocarcinoma was not included.

CONCLUSION

HPV-negative CIN2+ or cervical adenocarcinoma is not a concern for the introduction of primary HPV screening in Japan. Primary HPV testing in cervical cancer screening is considered a feasible method that can be used in Japan, although an algorithm suitable for Japan and a national-level management system need to be established.

Disparities in cervical cancer screening programs in Cameroon: a scoping review of facilitators and barriers to implementation and uptake of screening

BACKGROUND

Cervical cancer is the fourth most common cancer worldwide. Organized screening has achieved significant reductions in cervical cancer incidence and mortality in many high-income countries (HICs). But the gap between HICs and low-and-middle-income countries (LMICs) is still substantial as the highest burden of the disease is in LMICs. Cameroon is a LMIC, where cervical cancer is the leading cause of cancer-related deaths among women, only 3-5% of eligible women have been screened and there is no effective national cervical cancer prevention program.

OBJECTIVE(S)

Identify facilitators and barriers to the implementation and uptake of existing cervical cancer screening programs in Cameroon to inform the implementation of a comprehensive national program.

METHODS

We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-analysis, extension for Scoping Reviews (PRISMA-ScR). Google Scholar and five electronic databases (PubMed, CINAHL, Embase, Cochrane library and Web of Science) were searched systematically from 2012 to 2022. Articles on cervical cancer screening programs in Cameroon were eligible for inclusion. Two reviewers independently screened search results and extracted relevant data.

RESULTS

A total of 182 articles were identified using our search strategy, and 20 were included. There was scarcity of publications from the North, Adamawa, East and South regions of Cameroon. Barriers and facilitators found were presented using the World Health Organisation framework for health systems. Cross-cutting barriers were: (1) the lack of a national training curriculum for screening providers with no elaborate, harmonized screening and treatment algorithm for cervical precancers; and (2) women's lack of information about cervical cancer screening activities. Conversely, provision of screening services at a low or no cost to women in some programs and the feasibility of using novel point of care screening methods like the Human Papillomavirus DNA test were identified as facilitators.

CONCLUSION

This scoping review indicates that there are knowledge and research gaps concerning the state of cervical cancer screening services in some regions of Cameroon. Moreover, it underlines the need for comprehensive cancer control policies and practices integrating all six-health system building blocks to reduce disparities between regions, and rural versus urban areas in Cameroon.

Cervical Cancer Screening Recommendations: Now and for the Future

Cervical cancer is the fourth most common cancer worldwide, with over 600,000 new cases annually and approximately 350,000 cancer-related deaths per year. The disease burden is disproportionately distributed, with cancer-related mortality ranging from 5.2 deaths per 100,000 individuals in highly-developed countries, to 12.4 deaths per 100,000 in less-developed countries. This article is a review of the current screening recommendations and potential future recommendations.

Molecular markers predicting the progression and prognosis of human papillomavirus-induced cervical lesions to cervical cancer

INTRODUCTION

Persistent Human Papillomavirus (HPV) infection is linked to 99% of cervical cancer (CC) cases. HPV types 16 and 18 alone result in 75% of CC cases and thus are considered to be high-risk types (HR-HPV). CC is the third most common cancer among women globally. Approximately, 7000 patients die from it yearly. It is worthy to note that not every patient with HPV precancerous lesions will progress to CC.

OBJECTIVES

The objectives of this review is to explore the utilization of molecular and viral biomarkers as a tool for early detection and prediction of HPV-induced cervical lesions that might progress to CC.

METHODS

The data bases PubMed, Google Scholar, EBSCO were searched using keywords CC screening, HPV, and recent molecular biomarkers. The search time frame was within the last 7 years. Studies on HPV-induced cancers other than CC were excluded; a total of 200 eligible articles were retrieved.

RESULTS

In this review we explored the current literature about HPV virology, virulence genes and early diagnostic/prognostic molecular biomarkers in CC. The oncogenic property of HPV is attributed to viral expression of various early proteins (E5, E6, E7). The interaction between viral oncoproteins and the cellular genetic apparatus alters the expression of many genes at different phases of the disease. There was an association between cervical lesions induced by HR-HPV and the overexpression of markers of oxidative DNA damage and other proteins. The markers p16INK4a, programmed cell death-1 (PD-1)/programmed cell death ligand 1, mismatch repair enzymes (MMR), miRNA-377, claudin family (CLDN) are dysregulated and are associated with high risk lesions. Furthermore, advanced older cervical lesions were associated with high methylation levels and higher risk to progress to CC.

CONCLUSION

Adding different the above markers to the CC screening program scheme might offer a triage for prioritizing patient management.

Cumulative exposure to immunomodulators increases risk of cervical neoplasia in women with inflammatory bowel disease

BACKGROUND

Women with inflammatory bowel disease (IBD) are at increased risk of high-grade cervical intraepithelial neoplasia and cervical cancer (CIN2+).

AIM

To assess the association between cumulative exposure to immunomodulators (IM) and biologic agents (BIO) for IBD and CIN2+ METHODS: Adult women diagnosed with IBD before December 31st 2016 in the Dutch IBD biobank with available cervical records in the nationwide cytopathology database were identified. CIN2+ incidence rates in IM- (i.e., thiopurines, methotrexate, tacrolimus and cyclosporine) and BIO- (anti-tumour necrosis factor, vedolizumab and ustekinumab) exposed patients were compared to unexposed patients and risk factors were assessed. Cumulative exposure to immunosuppressive drugs was evaluated in extended time-dependent Cox-regression models.

RESULTS

The study cohort comprised 1981 women with IBD: 99 (5%) developed CIN2+ during median follow-up of 17.2 years [IQR 14.6]. In total, 1305 (66%) women were exposed to immunosuppressive drugs (IM 58%, BIO 40%, IM and BIO 33%). CIN2+ risk increased per year of exposure to IM (HR 1.16, 95% CI 1.08-1.25). No association was observed between cumulative exposure to BIO or both BIO and IM and CIN2+. In multivariate analysis, smoking (HR 2.73, 95%CI 1.77-4.37) and 5-yearly screening frequency (HR 1.74, 95% CI 1.33-2.27) were also risk factors for CIN2+ detection.

CONCLUSION

Cumulative exposure to IM is associated with increased risk of CIN2+ in women with IBD. In addition to active counselling of women with IBD to participate in cervical screening programs, further assessment of the benefit of intensified screening of women with IBD on long-term IM exposure is warranted.

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

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

A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania

BACKGROUND

Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania.

METHODS

An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results.

RESULTS

Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines.

CONCLUSION

This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

Cancer of the Cervix in Bulgaria: Epidemiology of a Crisis

Eastern Europe continues to have the highest rates of cancer of the uterine cervix (CUC) and human papillomavirus (HPV) infection in Europe.

AIM

The aim of this study was to investigate CUC trends in Bulgaria in the context of a lack of a population-based screening program and a demographic crisis.

METHODOLOGY

This was a retrospective study of 7861 CUC patients who were registered in the Bulgarian National Cancer Registry (BNCR) between 2013 and 2020 and followed up with until March 2022. We used descriptive statistics and modeling to assess temporal trends in new CUC incidence rates and identify factors associated with survival.

RESULTS

Bulgaria's population has decreased by 11.5% between 2011 and 2021. The CUC incidence rate decreased from 29.5/100,000 in 2013 to 23.2/100,000 in 2020 but remains very high. The proportion of patients diagnosed in earlier stages of CUC has decreased over time. Up to 19% of patients with CUC in Bulgaria are diagnosed between the age of 35 and 44 years. The median survival was 101.5 months, with some improvement in later years (adjusted HR = 0.83 for 2017-2020).

CONCLUSIONS

In countries with well-established population-based screening, CUC is nowadays considered a rare disease. However, it is not considered rare in Bulgaria. Population-based screening starting at an earlier age is the fastest way to improve outcomes.

Poor knowledge and awareness of human papillomavirus and cervical cancer among adult females in rural Ghana

Cervical cancer (CC) continues to be a global burden, and a disease of public health interest, especially in low- and middle-income countries. This study explored the knowledge and awareness of human papillomavirus (HPV) infection and CC and the risk-behavioural characteristics of an adult female population in rural Ghana. A total of 274 women, aged 21 years and above were recruited through multi-stage sampling. A questionnaire was used to obtain data on their socio-demographic and socio-economic characteristics and assess their knowledge and awareness of HPV and CC through face-to-face interviews. In all, 187 (68.2%) participants had poor knowledge of HPV and CC with 87 (31.8%) having good knowledge. Only 18.2% and 48.9% of them had prior awareness of HPV infection and CC, respectively. Their primary source of information was the broadcast media (TV and Radio stations) (60.1%). Regarding risky lifestyle behaviours, the mean age at sexual debut was 18.52 ± 2.39 years, 82.8% have had more than one lifetime sexual partner, 81.0% were multiparous with 51.5% using oral contraceptives. Women with higher educational attainment (cOR = 0.41; 95%CI = 0.20-0.81), monthly income (cOR = 0.31; 95%CI = 0.10-1.02), and lifetime sexual partners (aOR = 0.46; 95%CI = 0.21-1.00) were less likely to have poor CC and HPV knowledge compared to their counterparts. In conclusion, adult females in the rural population have limited knowledge and awareness of HPV infection and CC with low CC screening. Intensive educational campaigns should be organised and spearheaded on multiple platforms by the Ghana Health Service and civil societies to sensitise and educate women, in the rural parts of the country, on CC and its related preventive measures.

Comparison of primary cytology, primary HPV testing and co-testing as cervical cancer screening for Chinese women: a population-based screening cohort

OBJECTIVES

We compared clinical performance of three strategies of primary human papillomavirus (HPV) testing, primary cytology and co-testing for cervical cancer screening.

DESIGN

A population-based prospective cohort study of clinical performance of screening strategy.

SETTING

Patients recruited from community in Changzhi County, Shanxi Province, China.

PATIENT

3209 women aged 30-64 years without gynaecological issues.

PRIMARY AND SECONDARY OUTCOME MEASURES

The performance of different screening strategies for detecting cervical intraepithelial neoplasia grade 2 or more severe (CIN2+).

RESULTS

A total of 53 CIN2+ and 31 CIN3+ cases are detected. For CIN2+, sensitivity of primary HPV (95.9%) and co-testing (98.0%) are not statistically different, but significantly higher than primary cytology (48.0%). Specificity (86.8%), colposcopy referral rate (7.8%) and number of colposcopies required to detect one case (9.8) for primary HPV are better than co-testing (79.8%, 11.9%, 14.3%, respectively). For CIN3+, primary HPV, co-testing have 100% of sensitivity and specificity, which is significantly higher than primary cytology (56.7% and 90.2%). Number of colposcopies required to detect one case for primary HPV (15.9) is better than co-testing (23.8).

CONCLUSIONS

Compared with co-testing, HPV primary screening had comparable sensitivity and higher specificity for CIN2+ detection, and both of them showed better performance than cytology primary screening in cervical cancer screening.

Vaccination Coverage Against Human Papillomavirus in Female Students in Cyprus

Background Human papillomavirus (HPV) has been associated with the development of several cancers and cardiovascular diseases in females. Nevertheless, there is still poor data on vaccination coverage against HPV in several countries, including Cyprus. The main target of the present research was to assess the vaccination status of female students in Cyprus. Methodology An online survey was conducted via a cloud-based short questionnaire on Google Forms. Students with a known email address were initially invited via email to complete the survey. The questionnaire was distributed to 340 students, aged 18-49 years old, who lived in Cyprus (60% response rate). Results The total vaccination coverage was 38.1%. The mean age of participants was 23.5 (±6.5) years. The major reason for non-vaccination was the belief that participants were not at risk of serious illness from HPV infection (22%), followed by the reported lack of time to get vaccinated (16%) and inertia (13%). The students who had information about the safety of HPV vaccines from electronic sources of information (television, websites, and blogs) had lower vaccination coverage compared to those who had received information from alternative sources (primary health centers, family doctors, or obstetricians) (relative risk (RR) = 1.923, 95% confidence interval (CI) = 0.9669-3.825; p = 0.033). No significant differences in vaccination rates between participants who were coming from schools of health sciences versus those from financial schools (RR = 1.082, 95% CI = 0.7574-1.544; p = 0.3348) were observed. Conclusions Public health policy interventions and education on HPV vaccines are effective ways to improve the awareness and acceptance rate of HPV vaccination among female students and improve the HPV vaccination coverage level in Cyprus.