What is needed now for successful scale-up of screening?

Comparison of multiplex PCR capillary electrophoresis assay and PCR-reverse dot blot assay for human papillomavirus DNA genotyping detection in cervical cancer tissue specimens

Background

The study aimed to evaluate the positivity rates and genotype distribution of the multiplex PCR capillary electrophoresis (MPCE) and PCR-Reverse Dot Blot (PCR-RDB) assays for human papillomavirus (HPV) detection in cervical cancer tissue specimens, and to explore their detection principles and applications in large-scale population screening.

Methods

The MPCE and PCR-RDB assays were performed separately on 425 diagnosed cervical cancer tissue specimens. Subsequently, the results of both assays were compared based on the HPV infection positivity rates and genotype distribution.

Results

The overall positive rates of HPV genotypes for the MPCE and PCR-RDB assays were 97.9% and 92.9%, respectively. A p-value < 0.001 indicated a statistically significance difference in consistency between the two assays. The kappa value was 0.390, indicating that the consistency between both assays was fair. HPV16 was the most common single-genotype infection type, with infection rates detected via MPCE and PCR-RDB assays being 75.7% and 68.3%, respectively. In the age group >50 years, the HPV multiple-type infection rate detected via MPCE assay was significantly higher than that detected by the PCR-RDB assay, with a statistically significant difference (p = 0.002).

Conclusion

To reduce the false-negative rate and improve screening efficiency, the MPCE assay, which targets the oncogenic gene E6/E7 segments, can be extended to the general female population for the early detection, diagnosis, and treatment of cervical cancer.

An Overview of Cervical Cancer Prevention and Control in Latin America and the Caribbean Countries

Cervical cancer is a health crisis affecting women and their families across the world. It is known that developed countries have comprehensive protocols with recommendations regarding workforce, expertise, and medical resources to address this common cancer among women. In contrast, disparities in addressing cervical cancer remain present in Latin America and Caribbean countries. Here, we reviewed the current strategies of cervical cancer prevention and control in the region.

The recovery strategies to support cervical cancer elimination in lower-and middle-income countries (LMICs) following COVID-19 disruptions

The COVID-19 pandemic has exacerbated the existing challenges to achieving the WHO target of eliminating cervical cancer as a public health problem by working towards the target of fewer than four cases per 100 000 women. We reviewed the literature to identify potential recovery strategies to support cervical cancer prevention programs in lower-and middle-income countries (LMICs) following COVID-19 disruptions and the extent to which strategies have been implemented. Utilising the WHO health systems framework, we mapped these recovery strategies against the six building blocks to examine their reach across the health system. Most recovery strategies were focused on service delivery, while leadership and governance played a pivotal role in the continuity of cervical cancer prevention programs during the pandemic. Leadership and governance were the drivers for outcomes in the building blocks of health information systems, financing and critical support in operationalising service delivery strategies. In the aftermath of the COVID-19 pandemic with strained health resources and economies, stakeholders would significantly influence the coverage and sustainability of cervical cancer prevention programs. The support from multisectoral stakeholders would accelerate the recovery of cervical cancer prevention programs. To achieve the WHO target by 2030, we call for future studies to understand the barriers and facilitators from the perspectives of stakeholders in order to support the decision-making processes and information required to implement recovery strategies in LMICs.

Effectiveness of family-centred sexual health education and HPV self-sampling in promoting cervical cancer screening among hard-to-reach indian women in rural and tribal areas: a community-based pilot study

BACKGROUND

While cervical cancer deaths have declined steeply in high-income countries due to the widespread use of the Papanicolaou test (Pap test), the same trend has not emerged in low or middle-income countries (LMICs). Access to screening in LMICs like India is limited due to barriers such as limited healthcare infrastructures, lack of sexual health education, and stigma demarcating sexually transmitted infections (STIs). HPV self-sampling (HPV-SS), a woman-centered and at-home method for screening, can be utilized as a unique screening tool to overcome some of these barriers. Our study examined the effectiveness of HPV-SS, supported by family-centred arts-based sexual health literacy on the uptake of cervical cancer screening among hard-to-reach women in rural and remote areas in India.

METHODS

Our community-based mixed methods pilot study recruited 240 participants (120 women and 120 male partners or family members) through female Accredited Social Health Activists (ASHA) across 3 Indian villages of Shirgoan, Khodala, and Jamsar in Palghar district. Inclusion criteria included women ages 30-69 who were under or never screened (UNS) and their male partners/family members aged 18 or over. Knowledge and attitudes about cervical cancer and screening and their perceived stigma surrounding STI were assessed using validated scales prior to and after attending a 2-hour arts-based sexual health education (SHE). In addition, participants' uptake of cervical cancer screening was assessed after attendance in SHE.

FINDINGS

Results revealed significant improvement in knowledge and attitudes about cervical cancer and screening, and a reduction in the STI stigma after participation in SHE sessions (overall mean difference in Knowledge: z = 6.1 ± 2.4, P < 0.001; attitudes about Pap-test and VIA: z = 2.2 ± 8.4, P < 0.001 and z = 2.9 ± 8.2, P < 0.001; STI stigma: z = 2.8 ± 12.4, P < 0.001). 118 out of 120 female participants chose to be screened and 115 opted for HPV-SS.

CONCLUSIONS

The implementation of HPV-SS coupled with family-centered arts-based and culturally appropriate SHE is highly promising in promoting cervical cancer screening among hard-to-reach women. Evidence from our study can be used to advance public health policies and inform the scale-up of similar initiatives in other villages and states across rural India and other LMICs.

Follow-up on Women with Abnormal Findings of Cervical Cancer Screening in “The Americas” Region:

The Americas region ranks third in the world in incidence and mortality from cervical cancer among World Health Organization (WHO) regions. Several studies analyze screening coverage and accuracy of screening tests as the main reasons for lack of effectiveness; however, reports on follow-up of positive-screened women are scarce. Aim: To synthesize the existing knowledge about compliance with follow-up recommendations after an abnormal result of cervical cancer screening. Methods: We will search the PubMed via Medline and LILACS databases, with additional searches of grey literature. Inclusion criteria comprise studies on adult women from the Pan American Health Organization (PAHO) affiliated countries, with full text available and with specified data on follow-up outcomes. There are no language or publication date restrictions. Studies on special populations or including only women under age 25 will be excluded. Two reviewers will screen titles and abstracts independently, and two researchers will assess the methodological quality and risk of bias by using validated tools according to type of study. Disagreements will be solved by consensus. Discussion: This systematic review will provide information on differences and determinants of effective follow-up of positive-screened women in cervical cancer screening. The use of a Latin American database, the review of grey literature, and the inclusion of studies in all languages will allow us to identify more reports that might be relevant for low and middle income countries (LMIC) accounting with a high burden of disease.

Knowledge, Attitude, and Practice Toward Cervical Cancer Screening Among Female University Students in Ishaka Western Uganda

Purpose

Cervical cancer (CC) is the leading cause of cancer-related death among women living in third-world countries. CC is preventable, with the possibility of complete treatment if detected early. The objective of the study was to assess the level of knowledge, attitude, and practice on CC screening (CCS) among female university students (FUS) in Ishaka, western Uganda.

Methods

The study was a descriptive cross-sectional study among FUS (n = 407) in western Uganda conducted after the first nationwide lockdown in Uganda. Information was collected using a questionnaire and descriptively presented as frequency and percentages.

Results

The majority of our respondents were medical students 283 (69.5%), below 25 years 339 (83.3%), with Anglican Christian religious background 150 (36.9%). Respondents above the age of 25 years (p = 0.0052) and those in the medical profession (p < 0.001) had more knowledge. More medical students had a better attitude (p = 0.0043) and favorable practices (0.0134) compared to their non-medical counterparts. There is a weak correlation between attitude (r = 0.206, p < 0.001) and practice (r = 0.181, p = 0.0003) with knowledge on CCS.

Conclusion

Observation from the present study suggests the need for more efforts in the fight against cervical cancer and encouragement of positive attitude and practice towards cervical cancer screening and uptake of vaccination.

Mobilizing stakeholders to drive the cervical cancer elimination agenda in Kenya: The national cervical cancer stakeholders' forum 2022

Background

Kenya is among the nineteen countries in Sub-Saharan Africa with the highest burden of cervical cancer globally. The high burden of cervical cancer in developing countries reflects the absence of effective cervical cancer prevention programs with limited resources invested to provide comprehensive services.

Objective

We aimed to engage stakeholders in a structured consultative forum, to gain insights and forge effective partnerships to drive the cervical cancer elimination agenda in Kenya.

Methods

The National Cervical Cancer Stakeholders Consultative Forum was organized as a part of activities to commemorate the National Cervical Cancer Awareness Month on 19th January 2022 in Nairobi, Kenya. The overall goal of the meeting was to provide a forum to sensitize stakeholders on the National Cervical Cancer Prevention and Control Program (NCCP) with a view to strengthen partnerships, increase coordination for improved service delivery and to provide a forum for resource mobilisation and alignment of key stakeholders towards elimination of cervical cancer in Kenya. Nominal group technique was adopted for structured discussions, and the findings analysed to derive key themes.

Findings

Key challenges to primary and secondary prevention of cervical cancer were identified as low awareness, stigma and misinformation, high unmet need for treatment of early lesions, few health care providers with capacity to screen and treat, inadequate supplies, inefficient health information systems and poor referral pathways. Championing integration of cervical cancer screening and treatment services into routine health programs, strengthening policy implementation and robust monitoring and evaluation were identified as critical interventions.

Conclusion

The National Cervical Cancer Stakeholders Forum 2022 provided insights for enabling Kenya to progress on the 2030 elimination targets. Such forums can be useful in bringing all actors together to evaluate achievements and identify opportunities for more effective national cervical cancer prevention and control programs.

A Technical Comparison of Human Papillomavirus Genotyping Assays from a Population-Based Cervical Cancer Screening in South Central Ethiopia

Purpose

High-risk Human Papillomavirus (HPV) is the most important cause of cervical cancer. The highest burden of disease is seen in Low- and Low-Middle-Income Countries (LMIC). Several new HPV screening assays have been developed for high-risk HPV (hr-HPV) testing. We compared the performance and adequacy of three HPV genotyping assays on samples from a population of rural women in south-central Ethiopia.

Patients and Methods

One hundred and ten cervical swabs from rural women screened for HPV were assayed. HPV DNA was tested using MPG-Luminex Assay, Anyplex II HPV HR Detection, and EUROArray HPV. MPG-Luminex Assay was used as a reference method to compute the sensitivity and specificity of the two commercial assays in detecting hr-HPV infections.

Results

Of the 110 samples, MPG-Luminex Assay found 18.2% positive for the 14 hr-HPV and 7.3% for the probable hr-HPV genotypes. Anyplex™ II HPV HR Detection assay and EUROArray HPV Assay identified 21.82% and 12.7% samples, respectively, for the 14 hr-HPVs and both 7.3% for the probable hr-HPV genotypes (κ=0.734). Among the 14 hr-HPV genotypes, the genotype-specific agreement of the three HPV genotyping assays was moderate or better for HPV16, 31, 35, 39, 52, 56, 66 and 68. The aggregated sensitivity in detecting the 14 hr-HPV infections of Anyplex™ II HPV HR Detection and EUROArray HPV assays was high, 100% and 70%, respectively. The specificities of Anyplex™ II HPV HR Detection and EUROArray HPV were 95.6% and 100%, respectively.

Conclusion

The three evaluated assays showed similar analytical performance in the detection of hr-HPV infections and moderate or better concordance in HPV genotyping. This study is part of the ongoing cluster-randomized trial that has been registered in clinicaltrials.gov (NCT03281135) on September 13, 2017.

Clinical Performance of Triage Strategies for Hr-HPV-Positive Women; A Longitudinal Evaluation of Cytology, p16/K-67 Dual Stain Cytology, and HPV16/18 Genotyping

BACKGROUND

We evaluated the longitudinal performance of three options: HPV16/18 genotyping (HPV16/18), cytology (LBC), and p16/Ki-67 dual stain cytology (DS) for the triage of high-risk Human Papillomavirus-positive (Hr-HPV+) women within the cervical screening program in Scotland.

METHODS

Data were derived from a cohort of Hr-HPV+ women (n = 385) who participated in PaVDaG (Papillomavirus Dumfries and Galloway) study. Performance of triage strategies for detecting high-grade disease was assessed at 3 (in women <50 years) or 5 years (in women >50 years). Sensitivity, specificity, PPV, and cNPV of each triage test were calculated for CIN2+ and CIN3+ when used singly or sequentially.

RESULTS

The sensitivity of LBC (≥ borderline), DS, and HPV 16/18 genotyping for the detection of CIN2+ was 62.7% (50.7-73.3), 77.7% (63.1-83.7), and 62.7% (50.7-73.3) with corresponding cNPVs of 10.9%, 8.4%, and 11.9%. The option with the highest sensitivity and lowest cNPV was HPV 16/18 genotyping followed by LBC of Hr-HPV other+ and then DS of the LBC negatives. This yielded sensitivity of 94.7% (86.2-98.3) and cNPV 2.7% for CIN2+. Triage performance was similar if women had tested Hr-HPV+ positive by vaginal self-sampling.

CONCLUSIONS

Two-step triage with HPV 16/18 genotyping before LBC (or DS) for Hr-HPV other+ women was associated with a lower risk of significant disease at follow-up compared with single triage approaches.

IMPACT

This study provides longitudinal performance data on triage strategies in Hr-HPV+ women and will be informative for the evolution of cervical screening programs that increasingly rely on molecular technologies.

Factors influencing cervical cancer screening practice among female health workers in Nigeria: A systematic review

BACKGROUND

Cervical cancer is the most prevalent gynaecologic cancer in Nigeria. Despite being largely preventable through screening, cervical cancer is the second leading cause of cancer morbidity and mortality in Nigeria. To reduce the burden of cervical cancer in Nigeria, female health workers (FHWs) are expected to play an influential role in leading screening uptake and promoting access to cervical cancer education and screening.

AIM

The aim of this systematic review is to assess the factors influencing cervical cancer screening (CCS) practice among FHWs in Nigeria.

METHODS

We conducted a systematic literature search across six (6) electronic databases namely MEDLINE, Embase, Scopus, African Index Medicus, CINAHL, and Web of Science between May 2020 and October 2020. Reference list and grey literature search were conducted to complement database search. Four reviewers screened 3171 citations against the inclusion criteria and critically appraised the quality of eligible studies. Narrative synthesis was used in summarising data from included studies.

RESULTS

Overall, 15 studies met the inclusion criteria and were all quantitative cross-sectional studies. Included studies sampled a total of 3392 FHWs in Nigeria. FHWs had a high level of knowledge and positive attitude towards CCS. However, CCS uptake was poor. Predominant barriers to CCS uptake were the cost of screening, fear of positive results, lack of test awareness, reluctance to screen, low-risk perception, and lack of time. In contrast, being married, increasing age, awareness of screening methods, and physician recommendation were the most documented facilitators.

CONCLUSION

This study revealed that a complex interplay of socioeconomic, structural, and individual factors influences CCS among FHWs in Nigeria. Therefore, implementing holistic interventions targeting both health system factors such as cost of screening and infrastructure and individual factors such as low-risk perception and fear of positive result affecting FHWs in Nigeria is critical to reducing the burden of cervical cancer.

"When You Have Gotten Help, That Means You Were Strong": A Qualitative Study of Experiences in a "Screen and Treat" Program for Cervical Cancer Prevention in Malawi

Disproportionate cervical cancer burden falls on women in low-income countries, and there are new efforts to scale up prevention worldwide, including via "screen and treat" for detection and removal of abnormal cervical lesions. This study examines Malawian women's experiences with "screen and treat"; this is an under-explored topic in the literature, which has focused largely on knowledge about and attitudes toward screening, but not on experiences with screening. We interviewed 47 women who have been screened at least once for cervical cancer. The interview guide and analysis approach were informed by the Multi-Level Health Outcomes Framework. Women were recruited at facilities that offer "screen and treat" and asked about their experiences with screening. The average age of respondents was 40 years, and approximately half were HIV-negative. Although women were knowledgeable about the benefits of screening, they articulated many barriers including being turned away because of stock-outs of equipment, far distances to services, discomfort with male providers, and poor communication with providers. Alongside the many health education campaigns to increase awareness and demand for "screen and treat" services, the global public health community must also address implementation barriers in the resource-constrained health systems where burden is greatest. Particular attention should be paid to quality and person-centeredness of "screen and treat" services to optimize uptake and engagement in care.

Worldwide use of HPV self-sampling for cervical cancer screening

An increasing body of evidence supports the validity of self-sampling as an alternative to clinician collection for primary Human Papillomavirus (HPV) screening. Self-sampling effectively reaches underscreened women and can be a powerful strategy in low- and high-resource settings for all target ages. This work aims to summarize the current use of HPV self-sampling worldwide. It is part of a larger project that describes cervical cancer screening programmes and produces standardized coverage estimates worldwide. A systematic review of the literature and official documents supplemented with a formal World Health Organisation country consultation was conducted. Findings show that the global use of HPV self-sampling is still limited. Only 17 (12%) of countries with identified screening programs recommend its use, nine as the primary collection method, and eight to reach underscreened populations. We identified 10 pilots evaluating the switch to self-sampling in well-established screening programs. The global use of self-sampling is likely to increase in the coming years. COVID-19's pandemic has prompted efforts to accelerate HPV self-sampling introduction globally, and it is now considered a key element in scaling up screening coverage. The information generated by the early experiences can be beneficial for decision-making in both new and existing programs.

Human papillomavirus-independent cervical cancer

Cervical cancer is the fourth most frequent cancer in women worldwide, representing nearly 8% of all female cancer deaths every year. The majority of cases of cervical cancer are caused by human papillomavirus (HPV); however, up to 5% of tumors are not associated with HPV-persistent infection and, moreover, the new WHO Female Genital Tumors classification subdivided cervical squamous and adenocarcinomas into HPV-associated and HPV-independent tumors. Based on this new information, the aim of this review is to provide an overview of HPV-independent cervical cancer, evaluating diagnostic techniques, molecular profiles, and clinical outcomes. The HPV-independent tumors are characterized by a differentiated molecular profile with lower proliferative activity, a p53 immunostaining, a decreased expression of cyclin-dependent kinase inhibitor proteins, such as p16, p14, and p27, and alterations in PTEN, p53, KRAS, CTNNB1, ARID1A, and ARID5B HPV-independent tumors are associated with both adenocarcinomas and squamous histologic subtypes, with lymph node involvement in the early stages, more distant metastasis, and generally worse oncological outcomes. Thus far, no specific therapeutic strategies have been developed based on HPV status; however, with advancing knowledge of differences in the molecular profiles and possible targetable alterations, novel approaches may offer potential options in the near future. Investigators should report on clinical outcomes, evaluating the overall response rates to specific treatments, and consider new biomarkers to establish more accurate prognostics factors.

A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

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.

Comparison of the clinical and analytical performance of Alinity m HR HPV and cobas 4800 HPV assays in a population-based screening setting

BACKGROUND

The recently launched Abbott Alinity m HR HPV (Alinity) assay separately identifies high-risk human papillomavirus (hrHPV) genotypes HPV16, HPV18, and HPV45, and reports 11 other genotypes as two aggregates.

METHODS

Clinical and analytical performance of Alinity was compared with the cobas 4800 HPV assay on 4,334 women aged 20-64 years attending routine, population-based organized cervical cancer screening during 2009/2010. After 36 months, they were invited to participate in the second screening round (2012-2014) and later followed-up through centralized national cervical cancer screening registry.

RESULTS

In women 30 and older, the clinical sensitivity for cervical intraepithelial neoplasia grade 2+ (CIN2+) was 100.0% (95% CI, 88.2-100.0%) for Alinity and 100.0% (95% CI, 88.2-100.0%) for cobas, and for CIN3+ 100.0% (95% CI, 78.9-100.0%) for both assays. The clinical specificity for ≤ CIN1 in women 30 and older was 92.4% (95% CI, 91.4-93.3%) and 92.9% (95% CI, 91.9-93.7%), respectively. The assays demonstrated excellent overall agreement for hrHPV detection (97.9%) and genotype-specific agreement for HPV16 (99.6%), HPV18 (99.8%), and other hrHPV (98.1%). Overall positive agreement and positive agreements for HPV16, HPV18, and other hrHPV genotypes were 84.3%, 89.1%, 73.2%, and 82.3%. Based on a 5-year CIN3+ risk, slightly more HPV-positive women would require referral to immediate colposcopy after testing with Alinity vs. cobas (4.1% vs. 3.8%; p = 0.470), but significantly fewer Alinity-tested women would need a 6- to 12-month follow-up visit compared with those tested with cobas (5.0% vs. 8.6%; p < 0.0001).

CONCLUSIONS

Alinity and cobas have comparable clinical performance and showed excellent overall and genotype-specific agreement. The Alinity's extended genotyping ability could help predict the 5-year CIN3+ risk and cost-saving management of HPV-screen-positive women.

Changing the paradigm of cervical cancer prevention through introduction of HPV-testing: evaluation of the implementation process of the Jujuy Demonstration Project in Argentina

Introduction

The Jujuy Demonstration Project (JDP) was a project carried out over the course of 4 years (2011–2014) to develop, implement and evaluate the programmatic components of a Human Papilloma Virus (HPV)-based screening programme in Argentina. The aim of this paper is to present a qualitative evaluation of the context and implementation process of the JDP.

Methods

We used an adaptation of the Health System Framework (HSF), which includes interconnected contextual factors that are considered key drivers for successful health interventions. We reviewed secondary documents, which included scientific reports, norms and regulations, information sheets, power point presentations and manuals and recommendations published by the National Programme for Cervical Cancer Prevention. We also carried out semi-structured interviews with key informants to explore their views about technology acceptability.

Results

Key components of the JDP implementation process were: a high level of political support and consensus among stakeholders, the demonstrated effectiveness of the technology and its acceptability by health authorities and providers, the funding of tests and diagnosis/treatment services, the implementation of an information system for monitoring and evaluation and the reorganisation of the network of screening, diagnosis and treatment services.

Conclusion

This analysis examines the policy context in which the JDP was implemented and the system components that were key for the demonstrated effectiveness of the strategy. Such analyses provide useful insights into core components of HPV testing implementation that are needed to guarantee its potential effectiveness to reduce cervical cancer incidence and mortality.

Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach

The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.

Development and validation of an artificial intelligence system for grading colposcopic impressions and guiding biopsies

BACKGROUND

Colposcopy diagnosis and directed biopsy are the key components in cervical cancer screening programs. However, their performance is limited by the requirement for experienced colposcopists. This study aimed to develop and validate a Colposcopic Artificial Intelligence Auxiliary Diagnostic System (CAIADS) for grading colposcopic impressions and guiding biopsies.

METHODS

Anonymized digital records of 19,435 patients were obtained from six hospitals across China. These records included colposcopic images, clinical information, and pathological results (gold standard). The data were randomly assigned (7:1:2) to a training and a tuning set for developing CAIADS and to a validation set for evaluating performance.

RESULTS

The agreement between CAIADS-graded colposcopic impressions and pathology findings was higher than that of colposcopies interpreted by colposcopists (82.2% versus 65.9%, kappa 0.750 versus 0.516, p < 0.001). For detecting pathological high-grade squamous intraepithelial lesion or worse (HSIL+), CAIADS showed higher sensitivity than the use of colposcopies interpreted by colposcopists at either biopsy threshold (low-grade or worse 90.5%, 95% CI 88.9-91.4% versus 83.5%, 81.5-85.3%; high-grade or worse 71.9%, 69.5-74.2% versus 60.4%, 57.9-62.9%; all p < 0.001), whereas the specificities were similar (low-grade or worse 51.8%, 49.8-53.8% versus 52.0%, 50.0-54.1%; high-grade or worse 93.9%, 92.9-94.9% versus 94.9%, 93.9-95.7%; all p > 0.05). The CAIADS also demonstrated a superior ability in predicting biopsy sites, with a median mean-intersection-over-union (mIoU) of 0.758.

CONCLUSIONS

The CAIADS has potential in assisting beginners and for improving the diagnostic quality of colposcopy and biopsy in the detection of cervical precancer/cancer.

Integrative Systems Praxis for Implementation Research (INSPIRE): An Implementation Methodology to Facilitate the Global Elimination of Cervical Cancer

BACKGROUND

The World Health Organization (WHO) has called for a systems thinking approach to health systems strengthening to increase adoption of evidence-based interventions (EBI). The Integrative Systems Praxis for Implementation Research (INSPIRE) methodology operationalizes the WHO systems thinking framework to meet cervical cancer elimination-early detection and treatment (CC-EDT) goals.

METHODS

Using a systems thinking approach and grounded in the consolidated framework for implementation research, INSPIRE integrates multiple research methodologies and evaluation frameworks into a multilevel implementation strategy.

RESULTS

In phase I (creating a shared understanding), soft systems methodology and pathway analysis are used to create a shared visual understanding of the CC-EDT system, incorporating diverse stakeholder perspectives of the "what, how, and why" of system behavior. Phase II (finding leverage) facilitates active stakeholder engagement in knowledge transfer and decision-making using deliberative dialogues and multiple scenario analyses. Phase III (acting strategically) represents stakeholder-engaged implementation planning, using well-defined implementation strategies of education, training, and infrastructure development. In phase IV (learning and adapting), evaluation of key performance indicators via a reach, effectiveness, adoption, implementation, and maintenance framework is reviewed by stakeholder teams, who continuously adapt implementation plans to improve system effectiveness.

CONCLUSIONS

The INSPIRE methodology is a generalizable approach to context-adapted implementation of EBIs.

IMPACT

Replacing static dissemination of implementation "roadmaps" with learning health systems through the integration of systems thinking and participatory action research, INSPIRE facilitates the development of scalable and sustainable implementation strategies adapted to local contexts.

Outcomes in women with biopsy-confirmed cervical intraepithelial neoplasia grade 1 or normal cervix and related cofactors: A 15-year population-based cohort study from China

OBJECTIVE

To estimate long-term outcomes of biopsy-confirmed cervical intraepithelial neoplasia grade 1 (CIN1) or normal cervix and identify the cofactors during disease progression.

METHODS

In 1999, a cervical cancer screening cohort in Shanxi, China, enrolled 1997 women aged 35-45. They were followed up at year 6, 11, and 15 after enrollment with high-risk human papillomavirus (hrHPV) DNA testing, liquid-based cytology, and visual inspection with acetic acid. Progression, persistence, and regression rates were calculated, stratified by baseline hrHPV and cytological status. Risk factors associated with hrHPV acquisition, persistence, and progression were examined.

RESULTS

The cumulative rates of progression to CIN2+ among CIN1 over 6, 11, and 15 years were 7.5%, 21.4%, and 24.0%, respectively; the regression rates to normal cervix were 85.0%, 76.7%, and 72.9%, respectively. Over 6, 11, and 15 years, 0.7%, 2.9%, and 5.2% of normal cervix developed CIN2+, respectively, but over 90% remained normal after 15 years. CIN1 or normal cervix positive for hrHPV had significantly higher progression rates to CIN2+ than those without hrHPV. Similarly, the severity of cytological status was found to be associated with an increased risk of developing CIN2+. Women who had an earlier sexual debut were at a higher risk of acquiring new HPV infection and repeated HPV infections.

CONCLUSIONS

Clinical follow-up strategies for women with CIN1 or normal cervix could be adjusted accordingly based on hrHPV/cytology status.