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Stuart RM, Cohen JA, Kerr CC, Mathur P, Abeysuriya RG, Zimmermann M, Rao DW, Boudreau MC, Lee S, Yang L, Klein DJ. HPVsim: An agent-based model of HPV transmission and cervical disease. PLoS Comput Biol 2024; 20:e1012181. [PMID: 38968288 DOI: 10.1371/journal.pcbi.1012181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/20/2024] [Indexed: 07/07/2024] Open
Abstract
In 2020, the WHO launched its first global strategy to accelerate the elimination of cervical cancer, outlining an ambitious set of targets for countries to achieve over the next decade. At the same time, new tools, technologies, and strategies are in the pipeline that may improve screening performance, expand the reach of prophylactic vaccines, and prevent the acquisition, persistence and progression of oncogenic HPV. Detailed mechanistic modelling can help identify the combinations of current and future strategies to combat cervical cancer. Open-source modelling tools are needed to shift the capacity for such evaluations in-country. Here, we introduce the Human papillomavirus simulator (HPVsim), a new open-source software package for creating flexible agent-based models parameterised with country-specific vital dynamics, structured sexual networks, and co-transmitting HPV genotypes. HPVsim includes a novel methodology for modelling cervical disease progression, designed to be readily adaptable to new forms of screening. The software itself is implemented in Python, has built-in tools for simulating commonly-used interventions, includes a comprehensive set of tests and documentation, and runs quickly (seconds to minutes) on a laptop. Performance is greatly enhanced by HPVsim's multi-scale modelling functionality. HPVsim is open source under the MIT License and available via both the Python Package Index (via pip install) and GitHub (hpvsim.org).
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Affiliation(s)
- Robyn M Stuart
- Gender Equality Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jamie A Cohen
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Cliff C Kerr
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Prashant Mathur
- National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bangalore, India
| | - Romesh G Abeysuriya
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Burnet Institute, Melbourne, Victoria, Australia
| | - Marita Zimmermann
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Darcy W Rao
- Gender Equality Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Mariah C Boudreau
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Vermont Complex Systems Center, University of Vermont, Burlington, Vermont, United States of America
| | - Serin Lee
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of Industrial & Systems Engineering, University of Washington, Seattle, Washington, United States of America
| | - Luojun Yang
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Daniel J Klein
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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Basu P, Mwanahamuntu M, Pinder LF, Muwonge R, Lucas E, Nyambe N, Chisele S, Shibemba AL, Sauvaget C, Sankaranarayanan R, Prendiville W, Parham GP. A portable thermal ablation device for cervical cancer prevention in a screen-and-treat setting: a randomized, noninferiority trial. Nat Med 2024:10.1038/s41591-024-03080-w. [PMID: 38918630 DOI: 10.1038/s41591-024-03080-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/17/2024] [Indexed: 06/27/2024]
Abstract
Implementing standard-of-care cryotherapy or electrosurgical excision to treat cervical precancers is challenging in resource-limited settings. An affordable technological alternative that is as effective as standard-of-care techniques would greatly improve access to treatment. This randomized controlled trial aims to demonstrate the noninferiority efficacy of a portable, battery-driven thermal ablation (TA) device compared to cryotherapy and electrosurgical excision (large loop excision of transformation zone (LLETZ)) to treat cervical precancer in a screen-and-treat program in Zambia. A total of 3,124 women positive on visual inspection with acetic acid and eligible for ablative therapy were randomized to one of the treatment arms. Human papillomavirus (HPV) testing was performed at baseline and at the follow-up. The primary outcome was treatment success, defined as either type-specific HPV clearance at the follow-up in participants positive for HPV at baseline, or a negative visual inspection with acetic acid test for those who had a negative HPV test at baseline. After a median follow-up of 12 months, treatment success rates were 74.0%, 71.1% and 71.4% for the TA, cryotherapy and LLETZ arms, respectively, thus demonstrating noninferiority (P = 0.83). TA was a safe and well-accepted procedure. Only 3.6% of those randomized to TA reported moderate-to-severe pain, compared to 6.5% and 1.9% for the cryotherapy and LLETZ arms, respectively. Thus, our randomized controlled trial demonstrates the safety and efficacy of TA, which is not inferior to cryotherapy or surgical excision.ClinicalTrials.gov registration: NCT02956239 .
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Affiliation(s)
- Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France.
| | - Mulindi Mwanahamuntu
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Leeya F Pinder
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Richard Muwonge
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Eric Lucas
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Namakau Nyambe
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | - Samson Chisele
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
| | | | - Catherine Sauvaget
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Walter Prendiville
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, University Teaching Hospital, Lusaka, Zambia
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Papoutsis D, Underwood M, Parry-Smith W, Tzavara C. Endocervical crypt involvement by high-grade cervical intraepithelial neoplasia and its association with high-grade histopathological recurrence after cervical excision in women with negative excision margins: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:939-948. [PMID: 37821642 PMCID: PMC10867046 DOI: 10.1007/s00404-023-07242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND There is a growing body of evidence suggesting that endocervical crypt involvement by high-grade cervical intraepithelial neoplasia (CIN) may represent a risk factor for disease recurrence after cervical treatment. OBJECTIVES To provide a systematic review and meta-analysis on whether endocervical crypt involvement by high-grade CIN on the excised cervical specimen is associated with high-grade histopathological recurrence during the follow-up of women after cervical excisional treatment. SEARCH STRATEGY We searched the Medline, Scopus, Central, and Clinical Trials.gov databases from inception till May 2023. SELECTION CRITERIA Studies that reported on women with a single cervical treatment with any method of excision for CIN2 or CIN3 lesion, negative excision margins, and whose recurrence was defined histopathologically were included. DATA COLLECTION AND ANALYSIS Two reviewers independently evaluated study eligibility. We used the fixed effects model for meta-analysis. MAIN RESULTS There were 4 eligible studies included in the present systematic review that evaluated 1088 women treated with either large loop excision of the transformation zone (LLETZ) or with cold knife conization (CKC). We found no significant association of endocervical crypt involvement by CIN2-3 with high-grade histopathological recurrence at follow-up after cervical excision (OR 1.93; 95% CI 0.51-3.35). The subgroup analysis of women with LLETZ cervical excision showed again no significant association with high-grade histopathological recurrence at follow-up (OR 2.00; 95% CI 0.26-3.74). CONCLUSION Endocervical crypt involvement by high-grade CIN does not seem to be a risk factor for high-grade histopathological recurrence after cervical excision with negative excision margins.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK.
- School of Health Sciences, University of Western Macedonia, 50100, Ptolemaida, Kozani, PC, Greece.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Chara Tzavara
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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4
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Lee F, McGue S, Chapola J, Dunda W, Tang JH, Ndovie M, Msowoya L, Mwapasa V, Smith JS, Chinula L. Experiences of women participating in a human papillomavirus-based screen-triage-and treat strategy for cervical cancer prevention in Malawi. Front Oncol 2024; 14:1356654. [PMID: 38476363 PMCID: PMC10927745 DOI: 10.3389/fonc.2024.1356654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/26/2024] [Indexed: 03/14/2024] Open
Abstract
Objective To explore the experiences of Malawian women who underwent a human papillomavirus (HPV)-based screen-triage-treat algorithm for cervical cancer (CxCa) prevention. This algorithm included GeneXpert® HPV testing of self-collected vaginal samples, visual inspection with acetic acid (VIA) and colposcopy for HPV-positive women, and thermal ablation of ablation-eligible women. Method In-depth interviews were conducted with participants of a trial that evaluated the feasibility of a HPV-based screen-triage-treat algorithm among women living with HIV and HIV negative women in Lilongwe, Malawi. Participants were recruited from 3 groups: 1) HPV-negative; 2) HPV-positive/VIA-negative; 3) HPV-positive/VIA-positive and received thermal ablation. Interviews explored baseline knowledge of CxCa and screening, attitudes towards self-collection, and understanding of test results. Content analysis was conducted using NVIVO v12. Results Thematic saturation was reached at 25 interviews. Advantages of HPV self-collection to participants were convenience of sampling, same-day HPV results and availability of same-day treatment. There was confusion surrounding HPV-positive/VIA-negative results, as some participants still felt treatment was needed. Counseling, and in particular anticipatory guidance, was key in helping participants understand complex screening procedures and results. Overall, participants expressed confidence in the HPV screen-triage-treat strategy. Discussion HPV testing through self-collected samples is a promising tool to increase CxCa screening coverage. A multi-step screening algorithm utilizing HPV self-testing, VIA triage and thermal ablation treatment requires proper counseling and anticipatory guidance to improve patient understanding. Incorporating thorough counseling in CxCa screening programs can change women's perspectives about screening, build trust in healthcare systems, and influence healthcare seeking behavior towards routine screening and prevention.
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Affiliation(s)
- Fan Lee
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
| | - Shannon McGue
- Department of Medicine, Duke University, Durham, NC, United States
| | - John Chapola
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
| | - Wezzie Dunda
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jennifer H. Tang
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Margret Ndovie
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Lizzie Msowoya
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Victor Mwapasa
- Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jennifer S. Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Lameck Chinula
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
- Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Blantyre, Malawi
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5
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Mungo C, Osongo CO, Ambaka J, Omoto J, Cohen CR. Efficacy of thermal ablation for treatment of biopsy-confirmed high-grade cervical precancer among women living with HIV in Kenya. Int J Cancer 2023; 153:1971-1977. [PMID: 37715464 PMCID: PMC11081005 DOI: 10.1002/ijc.34737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 09/17/2023]
Abstract
The World Health Organization recommends thermal ablation (TA) as an alternative to cryotherapy within "screen-and-treat" cervical cancer programs in low- and middle-income countries (LMICs), including among women living with HIV (WLWH). Data on TA efficacy among WLWH are limited, however. We conducted a clinical trial to evaluate efficacy of TA for treatment of biopsy-confirmed cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3) among WLWH in Kenya. Nonpregnant HPV-positive WLWH age 25 to 65 years underwent colposcopy-directed biopsy, and same-day treatment with TA, if eligible. Women with biopsy-confirmed CIN2/3 at baseline had colposcopy-directed biopsies at 12 months to determine cure. A total of 376 participants underwent TA during the study period. At baseline, 238 (63.3%) had normal histology, 39 (10.4%) had CIN1, 15 (4.0%) had CIN2, 55 (14.6%) had CIN3, 7 (1.9%) had microinvasive cancer and 22 (5.6%) had indeterminate results. Twelve-month follow-up pathology results are available for 59 of 70 (84.3%) participants with CIN2/3 at baseline. Of these, 39 (66.1%, 95% CI 0.54-0.99) had successful treatment, defined as biopsy-confirmed CIN1 or normal findings, while 20 (33.9%, 95% CI 0.22-0.46) had treatment failure, defined as persistent biopsy-confirmed CIN2 or worse. Treatment failure was 23.1% (95% CI 0.17-0.46) and 39.9% (95% CI 0.23-0.51) among women with CIN2 and CIN3 at baseline, respectively. HIV-positive women with CIN2/3 have high rates of treatment failure at 1-year following thermal ablation. This highlights a significant limitation in the current WHO cervical cancer secondary-prevention strategy and calls for strategies to optimize cervical precancer treatment in this population.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
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Soler M, Lu E, Masch R, Alfaro K, Anderson JR, Cremer M. Affordable cancer technologies: Lessons learned from the design and implementation of two randomized clinical trials to develop innovative treatments for cervical precancer. Contemp Clin Trials Commun 2023; 36:101224. [PMID: 38028323 PMCID: PMC10663751 DOI: 10.1016/j.conctc.2023.101224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Montserrat Soler
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, San Salvador, El Salvador and Pittsburgh, PA, USA
| | | | - Rachel Masch
- Basic Health International, San Salvador, El Salvador and Pittsburgh, PA, USA
| | - Karla Alfaro
- Basic Health International, San Salvador, El Salvador and Pittsburgh, PA, USA
| | - Jean R. Anderson
- Jhpiego, Baltimore, MD, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Miriam Cremer
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, San Salvador, El Salvador and Pittsburgh, PA, USA
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7
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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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8
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Denny L, Saidu R, Boa R, Mbatani N, Castor D, Moodley J, Kuhn L. Point-of-care testing with Xpert HPV for single-visit, screen-and-treat for cervical cancer prevention: a demonstration study in South Africa. Sci Rep 2023; 13:16182. [PMID: 37758811 PMCID: PMC10533854 DOI: 10.1038/s41598-023-43467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023] Open
Abstract
Human papillomavirus (HPV)-based screen-and-treat (SAT) is recommended but implementation presents operational challenges. We implemented HPV-SAT at a research site in Khayelitsha, South Africa, screening 3062 women aged 30-65 years (44% women living with HIV [WHIV]). All were screened using point-of-care Xpert HPV and almost all received their HPV results on the same day. HPV-positivity occurred in 41.5% of WHIV and 17.4% of women without HIV (WNoH) reducing to 26.2% in WHIV and 10.4% in WNoH applying treatment eligibility criteria based on high viral load in the channels detecting HPV16, 18, 45, 16, 18, 31, 33, 35, 52, 58. Among those eligible for treatment, 91.3% were considered suitable for ablative therapy, and 94.6% underwent thermal ablation on the same day, with no serious adverse events. Twelve months later, 39.0% of WHIV and 65.2% of WNoH treated with ablative therapy were clear of HPV. In women who were HPV-positive but ineligible for treatment, 19.1% and 12.9% had histologically-confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+) at 12 months. SAT programs need to weigh trade-offs between overtreatment versus delayed or no treatment for women who test positive for HPV. Treatment modalities for precancerous lesions need to be improved.
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Affiliation(s)
- Lynette Denny
- Department Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department Obstetrics and Gynaecology, South African Medical Research Council, Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rakiya Saidu
- Department Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department Obstetrics and Gynaecology, South African Medical Research Council, Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rosalind Boa
- Department Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department Obstetrics and Gynaecology, South African Medical Research Council, Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Nomonde Mbatani
- Department Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department Obstetrics and Gynaecology, South African Medical Research Council, Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Delivette Castor
- Department Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, USA
- Division of Infectious Diseases, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, USA
| | - Jennifer Moodley
- Department Obstetrics and Gynaecology, South African Medical Research Council, Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Cancer Research Initiative and School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Louise Kuhn
- Department Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, USA.
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY, 10032, USA.
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Boisen M, Guido R. Emerging Treatment Options for Cervical Dysplasia and Early Cervical Cancer. Clin Obstet Gynecol 2023; 66:500-515. [PMID: 37650664 DOI: 10.1097/grf.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
DISCUSSION of treatment strategies for cervical cancer precursors, review of medical therapies and emerging therapeutics for treatment of cervical cancers, and updates on new approaches to treating early-stage cervical cancers.
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Affiliation(s)
- Michelle Boisen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
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10
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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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11
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Shimojo Y, Sudo K, Nishimura T, Ozawa T, Tsuruta D, Awazu K. Transient simulation of laser ablation based on Monte Carlo light transport with dynamic optical properties model. Sci Rep 2023; 13:11898. [PMID: 37488156 PMCID: PMC10366136 DOI: 10.1038/s41598-023-39026-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023] Open
Abstract
Laser ablation is a minimally invasive therapeutic technique to denature tumors through coagulation and/or vaporization. Computational simulations of laser ablation can evaluate treatment outcomes quantitatively and provide numerical indices to determine treatment conditions, thus accelerating the technique's clinical application. These simulations involve calculations of light transport, thermal diffusion, and the extent of thermal damage. The optical properties of tissue, which govern light transport through the tissue, vary during heating, and this affects the treatment outcomes. Nevertheless, the optical properties in conventional simulations of coagulation and vaporization remain constant. Here, we propose a laser ablation simulation based on Monte Carlo light transport with a dynamic optical properties (DOP) model. The proposed simulation is validated by performing optical properties measurements and laser irradiation experiments on porcine liver tissue. The DOP model showed the replicability of the changes in tissue optical properties during heating. Furthermore, the proposed simulation estimated coagulation areas that were comparable to experimental results at low-power irradiation settings and provided more than 2.5 times higher accuracy when calculating coagulation and vaporization areas than simulations using static optical properties at high-power irradiation settings. Our results demonstrate the proposed simulation's applicability to coagulation and vaporization region calculations in tissue for retrospectively evaluating the treatment effects of laser ablation.
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Affiliation(s)
- Yu Shimojo
- Graduate School of Medicine, Osaka Metropolitan University, Asahimachi 1-4-3, Abeno-ku, Osaka, 545-8585, Japan.
- Graduate School of Engineering, Osaka University, Yamadaoka 2-1, Suita, Osaka, 565-0871, Japan.
- Research Fellow of Japan Society for the Promotion of Science, Kojimachi 5-3-1, Chiyoda-ku, Tokyo, 102-0083, Japan.
| | - Kazuma Sudo
- Graduate School of Engineering, Osaka University, Yamadaoka 2-1, Suita, Osaka, 565-0871, Japan
| | - Takahiro Nishimura
- Graduate School of Engineering, Osaka University, Yamadaoka 2-1, Suita, Osaka, 565-0871, Japan.
| | - Toshiyuki Ozawa
- Graduate School of Medicine, Osaka Metropolitan University, Asahimachi 1-4-3, Abeno-ku, Osaka, 545-8585, Japan
| | - Daisuke Tsuruta
- Graduate School of Medicine, Osaka Metropolitan University, Asahimachi 1-4-3, Abeno-ku, Osaka, 545-8585, Japan
| | - Kunio Awazu
- Graduate School of Engineering, Osaka University, Yamadaoka 2-1, Suita, Osaka, 565-0871, Japan
- Global Center for Medical Engineering and Informatics, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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12
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Shin MB, Oluoch LM, Barnabas RV, Baynes C, Fridah H, Heitner J, Kerubo MB, Ngure K, Pinder LF, Thomas KK, Mugo NR, Gimbel S. Implementation and scale-up of a single-visit, screen-and-treat approach with thermal ablation for sustainable cervical cancer prevention services: a protocol for a stepped-wedge cluster randomized trial in Kenya. Implement Sci 2023; 18:26. [PMID: 37365575 PMCID: PMC10294443 DOI: 10.1186/s13012-023-01282-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND An important cervical cancer prevention strategy in low- and middle-income countries (LMICs) has been single-visit screen-and-treat (SV-SAT) approach, using visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy to manage precancerous lesions. While SV-SAT with VIA and cryotherapy have established efficacy, its population level coverage and impact on reducing cervical cancer burden remains low. In Kenya, the estimated cervical cancer screening uptake among women aged 30-49 is 16% and up to 70% of screen-positive women do not receive treatment. Thermal ablation for treatment of precancerous lesions of the cervix is recommended by the World Health Organization and has the potential to overcome logistical challenges associated with cryotherapy and facilitate implementation of SV-SAT approach and increase treatment rates of screen-positive women. In this 5-year prospective, stepped-wedge randomized trial, we plan to implement and evaluate the SV-SAT approach using VIA and thermal ablation in ten reproductive health clinics in central Kenya. METHODS The study aims to develop and evaluate implementation strategies to inform the national scale-up of SV-SAT approach with VIA and thermal ablation through three aims: (1) develop locally tailored implementation strategies using multi-level participatory method with key stakeholders (patient, provider, system-level), (2) implement SV-SAT approach with VIA and thermal ablation and evaluate clinical and implementation outcomes, and (3) assess the budget impact of SV-SAT approach with VIA and thermal ablation compared to single-visit, screen-and-treat method using cryotherapy. DISCUSSION Our findings will inform national scale-up of the SV-SAT approach with VIA and thermal ablation. We anticipate that this intervention, along with tailored implementation strategies will enhance the adoption and sustainability of cervical cancer screening and treatment compared to the standard of care using cryotherapy. TRIAL REGISTRATION NCT05472311.
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Affiliation(s)
- Michelle B Shin
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | | | - Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Colin Baynes
- Department of Global Health, University of Washington, Seattle, USA
| | - Harriet Fridah
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Jesse Heitner
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Leeya F Pinder
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | | | - Nelly Rwamba Mugo
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, USA
| | - Sarah Gimbel
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, USA
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13
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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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14
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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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15
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Zhang L, Sauvaget C, Mosquera I, Basu P. Efficacy, acceptability and safety of ablative versus excisional procedure in the treatment of histologically confirmed CIN2/3: A systematic review. BJOG 2023; 130:153-161. [PMID: 35689493 DOI: 10.1111/1471-0528.17251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Outcomes of earlier systematic reviews of the efficacy of ablative and excisional techniques to treat cervical intraepithelial neoplasia grade 2 or 3 (CIN2/3) were biased, as most of the included studies did not compare the techniques head-to-head. OBJECTIVE To systematically review the outcomes of studies comparing ablative and excisional techniques to treat CIN2/3 head-to-head. SEARCH STRATEGY Medline, Embase and Global Index Medicus were searched from inception until May 2021. SELECTION CRITERIA Studies directly comparing the efficacy and safety of excisional and ablative treatments on histologically confirmed CIN2/3. Eligibility criteria for the women treated with ablation had to be same as those treated with excision. DATA COLLECTION AND ANALYSIS A total of 323 articles were archived. Data on the risk of persistence/recurrence and safety were extracted from the original trials. Comparison between the two procedures was reported by forest plots, stratified by follow-up intervals and by HIV status. MAIN RESULTS Six publications were included. The risk of persistence/recurrence following ablation was significantly higher than that following excision (overall, RR 1.65, 95% CI 1.25-2.19; at 6-month follow-up, RR 1.94, 95% CI 1.29-2.91; at 12-month follow-up, RR 1.78, 95% CI 1.27-2.51; at 24-month follow-up, RR 1.57, 95% CI 1.11-2.23). The findings remained similar among women living with HIV (WLHIV). Both procedures were equally safe. CONCLUSIONS Excisional treatment was more effective than ablative treatment, with both procedures having similar safety profiles. Other programmatic considerations will guide the selection of technique, especially in resource-limited settings.
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Affiliation(s)
- Li Zhang
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Catherine Sauvaget
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Isabel Mosquera
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on Cancer, Lyon, France
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16
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Boles T, Salcedo MP, Lorenzoni C, Osman N, Baker E, Schmeler K, Carns J. Overview of thermal ablation devices for treating precancerous cervical lesions in low-resource settings. J Glob Health 2022; 12:03089. [PMID: 36579405 PMCID: PMC9798036 DOI: 10.7189/jogh.12.03089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Taylor Boles
- Rice360 Institute for Global Health Technologies, Rice University, Houston, Texas, USA
| | - Mila Pontremoli Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesaltina Lorenzoni
- Ministry of Health, Maputo, Republic of Mozambique,Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Nafissa Osman
- Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Ellen Baker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathleen Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Carns
- Rice360 Institute for Global Health Technologies, Rice University, Houston, Texas, USA,Department of Bioengineering, Rice University, Houston, Texas, USA
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17
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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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18
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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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19
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Sauvaget C, Bazikamwe S, Lucas E, Ndayikengurukiye A, Harerimana S, Barango P. Evaluation of effectiveness, acceptability and safety of thermal ablation in the treatment of cervical neoplasia in Burundi. Int J Cancer 2022; 151:1120-1126. [PMID: 35567576 DOI: 10.1002/ijc.34117] [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: 02/15/2022] [Revised: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 01/13/2023]
Abstract
This longitudinal study aimed at evaluating the effectiveness, acceptability and safety of the thermal ablation procedure (TA) in the treatment of cervical neoplasia. Women referred to the Gynaecology ward for symptoms or for opportunistic screening were assessed by visual inspection with acetic acid (VIA) and colposcopy. Those with lesions eligible to ablation were counselled and treated by TA. They were inquired about the level of pain during the procedure, and their level of satisfaction. Patients were followed up at 6 weeks for any complication and reassessed by VIA and colposcopy at 12 months for any persistent or recurrent lesion and for any adverse event. A total of 86 women with a positive VIA test were included in the study. The mean age was 46 years (28-61 years). Most of the women did not complain about any adverse event during treatment; one-third presented mild pain or cramp. At the 6-week visit, watery discharge was the main adverse event reported. All women were highly satisfied with TA and most of them would recommend it. At the 12-month visit, 82 women were examined (95% follow-up rate), and the overall cure rate was 96% (low-grade lesions: 98%; high-grade lesions: 94%). Three women presented low- and high-grade lesions that were treated by TA. No major adverse event or hospitalisation after the treatment was reported. In conclusion, TA was an effective procedure with a high cure rate at the 1-year follow-up visit. It was acceptable and safe, with only minor short-term side-effects reported and with a high satisfaction rate among the patients.
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Affiliation(s)
- Catherine Sauvaget
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer/World Health Organisation, Lyon, France
| | - Sylvestre Bazikamwe
- Department of Obstetrics and Gynaecology, Kamenge University Hospital, Burundi University, Bujumbura, Burundi
| | - Eric Lucas
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer/World Health Organisation, Lyon, France
| | - Athanase Ndayikengurukiye
- Department of Obstetrics and Gynaecology, Kamenge University Hospital, Burundi University, Bujumbura, Burundi
| | - Salvator Harerimana
- Department of Obstetrics and Gynaecology, Kamenge University Hospital, Burundi University, Bujumbura, Burundi
| | - Prebo Barango
- Intercountry Support Team for Eastern and Southern Africa, World Health Organisation African Region Office, Harare, Zimbabwe
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20
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Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT). THE LANCET GLOBAL HEALTH 2022; 10:e1336-e1346. [DOI: 10.1016/s2214-109x(22)00271-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/15/2022] [Accepted: 06/07/2022] [Indexed: 12/28/2022] Open
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21
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Dufeil E, Kenfack B, Tincho E, Fouogue J, Wisniak A, Sormani J, Vassilakos P, Petignat P. Addition of digital VIA/VILI to conventional naked-eye examination for triage of HPV-positive women: A study conducted in a low-resource setting. PLoS One 2022; 17:e0268015. [PMID: 35552564 PMCID: PMC9098068 DOI: 10.1371/journal.pone.0268015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 04/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND World Health Organization guidelines for cervical cancer screening recommend HPV testing followed by visual inspection with acetic acid (VIA) for triage if HPV positive. In order to improve visual assessment and identification of cervical intraepithelial neoplasia grade 2 and worse (CIN2+), providers may use visual aids such as digital cameras. OBJECTIVES To determine whether combined examination by naked-eye and digital VIA (D-VIA) and VILI (D-VILI) improves detection of CIN2+ as compared to the conventional evaluation. MATERIALS AND METHODS Women (30-49 years) living in Dschang (West Cameroon) were prospectively invited to a cervical cancer screening campaign. Primary HPV-based screening was followed by VIA/VILI and D-VIA/VILI if HPV-positive. Health care providers independently defined diagnosis (pathological or non-pathological) based on naked-eye VIA/VILI and D-VIA/VILI. Decision to treat was based on combined examination (VIA/VILI and D-VIA/VILI). Cervical biopsy and endocervical curettage were performed in all HPV-positive participants and considered as reference standard. Diagnostic performance of individual and combined naked-eye VIA/VILI and D-VIA/VILI was evaluated. A sample size of 1,500 women was calculated assuming a prevalence of 20% HPV positivity and 10% CIN2+ in HPV-positive women. RESULTS Due to the COVID-19 pandemic, the study had to terminate prematurely. A total of 1,081 women with a median age of 40 (IQR 35.5-45) were recruited. HPV positivity was 17.4% (n = 188) and 26 (14.4%) had CIN2+. Naked-eye VIA and D-VIA sensitivities were 80.8% (95% CI 60.6-93.4) and 92.0% (95% CI 74.0-99.0), and specificities were 31.2% (95% CI 24-39.1) and 31.6% (95% CI 24.4-39.6), respectively. The combination of both methods yielded a sensitivity of 92.3% (95% CI 74.9-99.1) and specificity of 23.2% (95% CI 16.8-30.7). A trend towards improved sensitivity was observed, but did not reach statistical significance. CONCLUSION Addition of D-VIA/VILI to conventional naked-eye examination may be associated with improved CIN2+ identification. Further studies including a larger sample size are needed to confirm these results.
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Affiliation(s)
- Eva Dufeil
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bruno Kenfack
- Faculty of Medicine and Pharmaceutical Science, University of Dschang, Dschang, Cameroon
- Department of Gynecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Evelyn Tincho
- Faculty of Medicine and Pharmaceutical Science, University of Dschang, Dschang, Cameroon
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon
| | - Jovanny Fouogue
- Department of Obstetrics and Gynecology, Bafoussam Regional hospital, Bafoussam, Cameroon
| | - Ania Wisniak
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- Population Epidemiology Unit, Department of Primary Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jessica Sormani
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, 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
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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22
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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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23
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Moucheraud C, Kawale P, Kafwafwa S, Bastani R, Hoffman RM. "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. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:405-413. [PMID: 32737829 PMCID: PMC7854805 DOI: 10.1007/s13187-020-01828-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- Corrina Moucheraud
- Fielding School of Public Health, University of California, Los Angeles, CA, USA.
| | - Paul Kawale
- African Institute for Development Policy, Lilongwe, Malawi
| | | | - Roshan Bastani
- Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Risa M Hoffman
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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24
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Mwanahamuntu M, Kapambwe S, Pinder LF, Matambo J, Chirwa S, Chisele S, Basu P, Prendiville W, Sankaranarayanan R, Parham GP. The use of thermal ablation in diverse cervical cancer "screen-and-treat" service platforms in Zambia. Int J Gynaecol Obstet 2022; 157:85-89. [PMID: 34197624 DOI: 10.1002/ijgo.13808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/30/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Thermal ablation (TA) was implemented in public sector cervical cancer prevention services in Zambia in 2012. Initially introduced as a treatment modality in primary healthcare clinics, it was later included in mobile outreach campaigns and clinical research trials. We report the feasibility, acceptability, safety, and provider uptake of TA in diverse clinical contexts. METHODS Screening services based on visual inspection with acetic acid were offered by trained nurses to non-pregnant women aged 25-59 years. Women with a type 1 transformation zone (TZ) were treated with same-visit TA. Those with a type 2 or 3 TZ, or suspicious for cancer, were managed with same-visit electrosurgical excision or punch biopsy, respectively. A provider survey was conducted. RESULTS Between 2012 and 2020, 2123 women were treated with TA: primary healthcare clinics, n = 746; mobile outreach clinics, n = 1127; research clinics, n = 250. Of the 996 women treated in primary healthcare and research clinics, 359 (48%) were HIV positive. Mild cramping during treatment was the most common adverse effect. No treatment interruptions occurred. No major complications were reported in the early (6 weeks) follow-up period. Providers expressed an overwhelming preference for TA over cryotherapy. CONCLUSION TA was feasible, safe, and acceptable in diverse clinical contexts. It was the preferred ablation method of providers when compared with cryotherapy.
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Affiliation(s)
- Mulindi Mwanahamuntu
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia
| | | | - Leeya F Pinder
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Jane Matambo
- Center for Infectious Disease Research in Zambia, Cervical Cancer Prevention Program, Lusaka, Zambia
| | - Susan Chirwa
- Center for Infectious Disease Research in Zambia, Cervical Cancer Prevention Program, Lusaka, Zambia
| | - Samson Chisele
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia
| | - Partha Basu
- International Agency for Research on Cancer, WHO Screening Group, Early Detection and Prevention Section, Lyon, France
| | - Walter Prendiville
- International Agency for Research on Cancer, WHO Screening Group, Early Detection and Prevention Section, Lyon, France
| | - Rengaswamy Sankaranarayanan
- International Agency for Research on Cancer, WHO Screening Group, Early Detection and Prevention Section, Lyon, France
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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25
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Nguyen DTN, Simms KT, Keane A, Mola G, Bolnga JW, Kuk J, Toliman PJ, Badman SG, Saville M, Kaldor J, Vallely A, Canfell K. Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea. BMJ Glob Health 2022; 7:bmjgh-2021-007380. [PMID: 35241461 PMCID: PMC8896000 DOI: 10.1136/bmjgh-2021-007380] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/23/2021] [Indexed: 01/22/2023] Open
Abstract
Introduction WHO has launched updated cervical screening guidelines, including provisions for primary HPV screen-and-treat. Papua New Guinea (PNG) has a high burden of cervical cancer, but no national cervical screening programme. We recently completed the first field trials of a screen-and-treat algorithm using point-of-care self-collected HPV and same-day treatment (hereafter self-collected HPV S&T) and showed this had superior clinical performance and acceptability to visual inspection of the cervix with acetic acid (VIA). We, therefore, evaluated the effectiveness, cost-effectiveness and resource implications of a national cervical screening programme using self-collected HPV S&T compared with VIA in PNG. Methods An extensively validated platform (‘Policy1-Cervix’) was calibrated to PNG. A total of 38 strategies were selected for investigation, and these incorporated variations in age ranges and screening frequencies and allowed for the identification of the optimal strategy across a wide range of possibilities. A selection of strategies that were identified as being the most effective and cost-effective were then selected for further investigation for longer-term outcomes and budget impact estimation. In the base case, we assumed primary HPV testing has a sensitivity to cervical intraepithelial neoplasia 2 (CIN2+) + of 91.8% and primary VIA of 51.5% based on our earlier field evaluation combined with evidence from the literature. We conservatively assumed HPV sampling and testing would cost US$18. Costs were estimated from a service provider perspective based on data from local field trials and local consultation. Results Self-collected HPV S&T was more effective and more cost-effective than VIA. Either twice or thrice lifetime self-collected HPV S&T would be cost-effective at 0.5× gross domestic product (GDP) per capita (incremental cost-effectiveness ratio: US$460–US$656/life-years saved; 1GDPper-capita: US$2829 or PGK9446 (year 2019)) and could prevent 33 000–42 000 cases and 23 000–29 000 deaths in PNG over the next 50 years, if scale-up reached 70% coverage from 2023. Conclusion Self-collected HPV S&T was effective and cost-effective in the high-burden, low-resource setting of PNG, and, if scaled-up rapidly, could prevent over 20 000 deaths over the next 50 years. VIA screening was not effective or cost-effective. These findings support, at a country level, WHO updated cervical screening guidelines and indicate that similar approaches could be appropriate for other low-resource settings.
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Affiliation(s)
| | - Kate T Simms
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Adam Keane
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Glen Mola
- Department of Reproductive Health, Obstetrics and Gynecology, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, CND, Papua New Guinea.,Department of Obstetrics and Gynecology, Port Moresby General Hospital, Port Moresby, Papua New Guinea
| | - John Walpe Bolnga
- Department of Obstetrics and Gynecology, Modilion Hospital, Mango, Madang, Papua New Guinea
| | - Joseph Kuk
- Department of Obstetrics and Gynecology, Mt Hagen Provincial Hospital, Mt Hagen, Western Highlands Province, Papua New Guinea
| | - Pamela J Toliman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Steven G Badman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Marion Saville
- Australian Centre for the Prevention of Cervical Cancer, Melbourne, Victoria, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Vallely
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, Sydney, New South Wales, Australia
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26
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A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial. Contemp Clin Trials Commun 2022; 26:100903. [PMID: 35243124 PMCID: PMC8857441 DOI: 10.1016/j.conctc.2022.100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 01/25/2023] Open
Abstract
Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.
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27
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Papoutsis D, Williams J, Underwood M, Parry-Smith W. Healing pattern of the cervical stroma following cold coagulation treatment for cervical intraepithelial neoplasia: A case report. Oncol Lett 2022; 23:81. [PMID: 35126723 DOI: 10.3892/ol.2022.13201] [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: 08/02/2021] [Accepted: 11/05/2021] [Indexed: 11/06/2022] Open
Abstract
Cold coagulation of the cervix for cervical intraepithelial neoplasia (CIN), when compared with cervical excision, has previously demonstrated comparable cure rates and a reduction in the rate of spontaneous preterm birth. In the present report the healing pattern in the cervices of two women after cold coagulation is described. Both women underwent cold coagulation due to CIN3, which was found on pre-treatment cervical punch biopsies. They were followed up after cold coagulation and at 7 and 18 months, respectively, they underwent cervical excision. The histopathological slides from the excised specimen were reviewed, which represents the healed cervix after cold coagulation. A clear boundary of collagenisation was noted in the superficial stroma, which appeared to stop at the junction with the healthy muscular stroma. The collagenised superficial stroma depth, which represents the area that was thermally ablated and has now healed, measured 1.6 and 1.5 mm for the two women, respectively, which is less compared with that typically removed by cervical excision. Observations from these two cases indicate that cold coagulation does not appear to disrupt the deep tissue architecture of the cervix and could therefore explain the reduced levels of adverse obstetric morbidity in patients who underwent cold coagulation ablative treatment of the cervix, which has been previously reported.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK.,Midwifery Department, School of Health Sciences, University of Western Macedonia, 50200 Kozani, Greece
| | - Joanna Williams
- Department of Histopathology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford TF16TF, UK
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28
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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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29
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Broutet N, Jeronimo J, Kumar S, Almonte M, Murillo R, Huy NVQ, Denny L, Kapambwe S, Bhatla N, Sebitloane M, Zhao F, Gravitt P, Adsul P, Rangaraj A, Dalal S, Newman M, Chowdhury R, Church K, Nakisige C, Diop M, Parham G, Thomson KA, Basu P, Steyn P. Implementation research to accelerate scale-up of national screen and treat strategies towards the elimination of cervical cancer. Prev Med 2022; 155:106906. [PMID: 34896155 DOI: 10.1016/j.ypmed.2021.106906] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths of women per year globally, mostly in low- and middle-income countries. In 2018 the WHO Director General made a call to action for the elimination of cervical cancer as a public health problem. MAIN BODY New thinking on programmatic approaches to introduce emerging technologies and screening and treatment interventions of cervical precancer at scale is needed to achieve elimination goals. Implementation research (IR) is an important yet underused tool for facilitating scale-up of evidence-based screening and treatment interventions, as most research has focused on developing and evaluating new interventions. It is time for countries to define their specific IR needs to understand acceptability, feasibility, and cost-effectiveness of interventions as to design and ensure effective implementation, scale-up, and sustainability of evidence-based screening and treatment interventions. WHO convened an expert advisory group to identify priority IR questions for HPV-based screening and treatment interventions in population-based programmes. Several international organizations are supporting large scale introduction of screen-and-treat approaches in many countries, providing ideal platforms to evaluate different approaches and strategies in diverse national contexts. CONCLUSION For reducing cervical cancer incidence and mortality, the readiness of health systems, the reach and effectiveness of new technologies and algorithms for increasing screening and treatment coverage, and the factors that support sustainability of these programmes need to be better understood. Answering these key IR questions could provide actionable guidance for countries seeking to implement the WHO Global Strategy towards cervical cancer elimination.
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Affiliation(s)
| | - Jose Jeronimo
- Consultant for the US National Cancer Institute, MD, USA
| | | | - Maribel Almonte
- International Agency for Research in Cancer (IARC), Lyon, France
| | | | | | | | | | - Neerja Bhatla
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Fanghui Zhao
- Chinese Academy of Medical Sciences, Beijing, China
| | - Patti Gravitt
- University of Maryland Baltimore, Baltimore, MD, USA
| | - Prajakta Adsul
- University of New Mexico Comprehensive Cancer Center, USA
| | | | - Shona Dalal
- World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Mamadou Diop
- Cancer Institute, Le Dantec Hospital, Cheikh Anta Diop University, Senegal
| | - Groesbeck Parham
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kerry A Thomson
- PATH, Sexual & Reproductive Health Program, Seattle, WA, USA
| | - Partha Basu
- International Agency for Research in Cancer (IARC), Lyon, France
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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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Ragupathy K, Jayasinghe T, McMullen W. Thermal Ablation of High-Grade Premalignant Disease of the Cervix-Standing the Test of Time: A Retrospective Study. J Low Genit Tract Dis 2022; 26:27-31. [PMID: 34928251 DOI: 10.1097/lgt.0000000000000638] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Analyze long-term (20 years) cytology and histology outcomes after treatment of high-grade cervical intraepithelial neoplasia (HGCIN) with thermal ablation (TA). METHODS All women having TA for HGCIN between January 1996 and December 1998 (36 months; N = 885) were identified; data were collected on age of patients, symptoms, colposcopy findings, and biopsy reports. Local and national (cytology and colposcopy) databases and colposcopy records were used to collect long-term follow-up data. Probability of CIN recurrence was assessed using Kaplan-Meier "survival" curve. RESULTS Follow-up data (available for 796) was collected in 2018 capturing 20 years of follow-up data. Two hundred eighty-one women were treated for CIN 2 and 515 women for CIN 3. Seven hundred ninety-one of 796 (>99%) were treated at first visit. Two hundred sixty two of 796 (33%) had evidence of crypt involvement on pretreatment biopsy. Probability of having consistently normal cytological follow-up was 92%, 89%, 86%, and 83% at 5, 10, 15, and 20 years, respectively. Cumulative probability of having recurrent HGCIN was 0.5% at 5 years, 1% at 10 years, 1.9% at 15 years, and 3% at 18 years. There was 1 invasive squamous cell cancer at 11 years after treatment. CONCLUSIONS Thermal ablation is a safe and effective treatment for HGCIN, which is now shown to have stood the test of time. We advise more widespread adoption in the United Kingdom and globally so long as agreed criteria are met.
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Affiliation(s)
- Kalpana Ragupathy
- Gynaecology Department, NHS Tayside, Ninewells Hospital, Dundee, United Kingdom
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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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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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Prevention of cervical cancer through two HPV-based screen-and-treat implementation models in Malawi: protocol for a cluster randomized feasibility trial. Pilot Feasibility Stud 2021; 7:98. [PMID: 33879259 PMCID: PMC8056631 DOI: 10.1186/s40814-021-00839-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/13/2021] [Indexed: 12/29/2022] Open
Abstract
Background Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease. Implementing a cervical cancer screening and preventive treatment (CCSPT) program that utilizes rapid human papillomavirus (HPV) testing on self-collected cervicovaginal samples for screening and thermal ablation for treatment may achieve greater coverage than current programs that use visual inspection with acetic acid (VIA) for screening and cryotherapy for treatment. Furthermore, self-sampling creates the opportunity for community-based screening to increase uptake in populations with low screening rates. Malawi’s public health system utilizes regularly scheduled outreach and village-based clinics to provide routine health services like family planning. Cancer screening is not yet included in these community services. Incorporating self-sampled HPV testing into national policy could address cervical cancer screening barriers in Malawi, though at present the effectiveness, acceptability, appropriateness, feasibility, and cost-effectiveness still need to be demonstrated. Methods We designed a cluster randomized feasibility trial to determine the effectiveness, acceptability, appropriateness, feasibility, and budget impact of two models for integrating a HPV-based CCSPT program into family planning (FP) services in Malawi: model 1 involves only clinic-based self-sampled HPV testing, whereas model 2 includes both clinic-based and community-based self-sampled HPV testing. Our algorithm involves self-collection of samples for HPV GeneXpert® testing, visual inspection with acetic acid for HPV-positive women to determine ablative treatment eligibility, and same-day thermal ablation for treatment-eligible women. Interventions will be implemented at 14 selected facilities. Our primary outcome will be the uptake of cervical cancer screening and family planning services during the 18 months of implementation, which will be measured through an Endline Household Survey. We will also conduct mixed methods assessments to understand the acceptability, appropriateness, and feasibility of the interventions, and a cost analysis to assess budget impact. Discussion Our trial will provide in-depth information on the implementation of clinic-only and clinic-and-community models for integrating self-sampled HPV testing CCSPT with FP services in Malawi. Findings will provide valuable insight for policymakers and implementers in Malawi and other resource-limited settings with high cervical cancer burden. Trial registration ClinicalTrials.gov identifier: NCT04286243. Registered on February 26, 2020.
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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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Wentzensen N, Chirenje ZM, Prendiville W. Treatment approaches for women with positive cervical screening results in low-and middle-income countries. Prev Med 2021; 144:106439. [PMID: 33678236 DOI: 10.1016/j.ypmed.2021.106439] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
The primary goal of cervical screening is to identify women with cervical precancers who need treatment to prevent invasive cervical cancer. Cervical cancer screening programs in high-resource settings rely on a multi-step process to reassure the majority of women of low cancer risk and treat the small number of women at high risk of precancer and cancer. The requirement of major resource investment for training and capacity building of multi-step cervical cancer screening programs prevents their introduction in low- and middle-income countries (LMICs). Screen-and-treat programs have been evaluated and introduced in some countries that use mainly ablative treatment as primary treatment options. Ablative treatment with cryotherapy and thermal ablation has a favorable tradeoff of benefits and harms and can be introduced more widely than excisional treatment in LMICs. While most women below 40 are eligible for ablative procedures, fewer than 50% are eligible by age 50 and ablative treatment is not appropriate over age 50. Excisional treatment is required for women ineligible for ablative treatment. Since screening programs in LMICs necessarily detect invasive cancers, cancer treatment and palliative care needs to be considered as well.
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Affiliation(s)
- Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
| | - Z Mike Chirenje
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe and Bixby Center for Global Health, UCSF, San Francisco, USA
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Joshi S, Muwonge R, Kulkarni V, Lucas E, Kulkarni S, Kand S, Mandolkar M, Baig M, Wankhede S, Surwase K, Pardeshi D, Basu P, Rengaswamy S. Mobile Screening Unit (MSU) for the Implementation of the 'Screen and Treat' Programme for Cervical Cancer Prevention In Pune, India. Asian Pac J Cancer Prev 2021; 22:413-418. [PMID: 33639655 PMCID: PMC8190336 DOI: 10.31557/apjcp.2021.22.2.413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/19/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES We are reporting the evaluation of an opportunistic point of care cervical cancer screening initiative in Pune, India using a mobile screening unit (MSU). METHODS We conducted 290 cervical cancer screening outreach clinics in the MSU. Screening was performed by trained nurses/ health care providers using visual inspection with 5% acetic acid (VIA). Screen positive women when eligible were treated by thermal ablation during the same sitting. Women with large lesions not eligible for treatment with thermal ablation were referred for colposcopy and treatment. RESULTS A total of 10, 925 women were screened between Nov 2016 and June 2019 in 290 outreach clinics in the MSU. The overall screen positivity was 6.6% (95% CI 6.1, 7.0) with a declining trend over time. A total of 304/717 (42.4%, 95% CI 38.7, 46.1) women received treatment with thermal ablation. About 3.6% (11/304) reported minor side effects and 1.6% (5/304) reported lower abdominal pain and all of them subsided after treatment. Among the 413 women who were advised colposcopy, only 84 (20.33%) women underwent the procedure. Of these 84 women, 64 (76.19%) had normal colposcopy/ histopathology, 7 (8.33%) had CIN1, 2 (2.38%) had CIN 2, 9 (10.71%) had CIN 3 disease and 2 (2.38%) women were diagnosed with invasive cancer. CONCLUSION MSUs are useful for providing cervical cancer screening services, using the 'screen and treat' strategy. Thermal ablation is safe in the field clinics. Additional efforts are needed to improve the compliance for referral of those with large lesions requiring additional visits.
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Affiliation(s)
- Smita Joshi
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France.
| | - Vinay Kulkarni
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Eric Lucas
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France.
| | - Sanjeevani Kulkarni
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Seema Kand
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Mahesh Mandolkar
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Mufid Baig
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Sudhakar Wankhede
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Kavita Surwase
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Dilip Pardeshi
- Prayas, Amrita Clinic, Athawale Corner, Karve Road, Deccan Gymkhana, Pune 411 004, India.
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France.
| | - Sankaranarayanan Rengaswamy
- Research Triangle Institute, International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India.
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Moucheraud C, Kawale P, Kafwafwa S, Bastani R, Hoffman RM. Health care workers' experiences with implementation of "screen and treat" for cervical cancer prevention in Malawi: A qualitative study. Implement Sci Commun 2020; 1:112. [PMID: 33317633 PMCID: PMC7734769 DOI: 10.1186/s43058-020-00097-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/25/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. "Screen and treat" (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing "screen and treat" from the provider perspective, or about thermocoagulation as a lesion removal technique. METHODS Informed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced "screen and treat" providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings. RESULTS Seven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents' knowledge and beliefs about providing "screen and treat" (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide "screen and treat" to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services). CONCLUSIONS Although "screen and treat" is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.
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Affiliation(s)
- Corrina Moucheraud
- University of California Fielding School of Public Health, Los Angeles, CA USA
| | - Paul Kawale
- African Institute for Development Policy, Lilongwe, Malawi
| | | | - Roshan Bastani
- University of California Fielding School of Public Health, Los Angeles, CA USA
| | - Risa M. Hoffman
- University of California Geffen School of Medicine, Los Angeles, CA USA
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Paolino M, Gago J, Pera AL, Cinto O, Thouyaret L, Arrossi S. Adherence to triage among women with HPV-positive self-collection: a study in a middle-low income population in Argentina. Ecancermedicalscience 2020; 14:1138. [PMID: 33281930 PMCID: PMC7685770 DOI: 10.3332/ecancer.2020.1138] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Screening for cervical cancer (CC) prevention has substantially changed with the introduction of human papillomavirus (HPV) tests. This technology compared to cytology has increased the detection of pre-malignant and malignant cervical lesions in real-world programmes in different settings. Very importantly, through self-collection, HPV testing can reduce barriers to screening and increase coverage. However, when using HPV self-collection, triage tests are a key step in the CC prevention process, and high adherence to triage has been difficult to obtain in low-middle income settings. The aim of this study was to measure adherence to triage among women with HPV+ self-collection and analysed factors associated with this adherence in a middle-low resource setting in Argentina. We also evaluated key indicators related to the implementation of the HPV self-collection strategy. Methods We analysed data on screening/triage/diagnosis/treatment from women aged 30+ who performed self-collection between 2015 and 2017 (n = 15,763), in the public health system in Tucuman, Argentina. We analysed secondary data from the national screening information system. The primary outcomes were: 1) adherence to cytology triage within the recommended timeframe (120 days) and 2) overall adherence to cytology triage including data at 18 months after screening. Multivariable regression was used to examine the association between age group, year of the screening test, record of the previous Pap-based screening and health insurance status with adherence to triage test as a primary outcome. We reported odds ratios, 95% confidence intervals and p-value of 0.05, which was considered the threshold for p-values). Results We analysed data of 2,389 HPV+ women. The overall adherence to triage at 18 months was 42.9%. The percentage of women completing cytology triage within the recommended timeframe of 120 days was lower (25.2%). Women with the record of a previous Pap-based screening had 1.86 times the odds of having a triage compared to women without a record of a previous Pap-based screening (95% CI: 1.64–2.64, p <0.001). Furthermore, the probability of having triage at the recommended timeframe was higher among women who were older and women with public health insurance. Conclusions Our results showed that adherence to triage in the recommended timeframe was low. In addition, the probability of having triage at the recommended timeframe was higher among women with a record of a previous Pap-based screening, a proxy of the use of health services. Our results showed that adherence to triage in the context of the HPV-self-collection strategy is challenging. The implementation of alternative approaches that might facilitate adherence to triage should be further investigated.
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Affiliation(s)
- Melisa Paolino
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas, Sánchez de Bustamante 27, Buenos Aires 1193, Argentina.,https://orcid.org/0000-0002-8649-1570
| | - Juan Gago
- Department of Population Health, School of Medicine, New York University (NYU), 550 1st Avenue, New York, NY 10016, USA
| | - Anabella Le Pera
- Centro de Estudios de Estado y Sociedad, Sánchez de Bustamante 27, Buenos Aires 1193, Argentina
| | - Oscar Cinto
- Ministerio de Salud Pública de Tucumán, Av. República del Líbano 956, San Miguel de Tucumán, Tucumán, Argentina.,Retired
| | - Laura Thouyaret
- Programa Nacional de Prevención de Cáncer Cervicouterino /Instituto Nacional del Cáncer (Argentina), Julio A, Roca 781, Piso 9, Buenos Aires 1067, Argentina
| | - Silvina Arrossi
- Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas, Sánchez de Bustamante 27, Buenos Aires 1193, Argentina.,https://orcid.org/0000-0002-5071-0938
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Slavkovsky RC, Bansil P, Sandoval MA, Figueroa J, Rodriguez DM, Lobo JS, Jeronimo JA, de Sanjosé S. Health Outcomes at 1 Year After Thermal Ablation for Cervical Precancer Among Human Papillomavirus- and Visual Inspection With Acetic Acid-Positive Women in Honduras. JCO Glob Oncol 2020; 6:1565-1573. [PMID: 33074738 PMCID: PMC7605374 DOI: 10.1200/go.20.00400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE This study aims to assess the detection of cervical intraepithelial lesions grades 2 and 3 (CIN2-3) at 1 year after treatment with thermal ablation among human papillomavirus (HPV)–positive and visual inspection with acetic acid (VIA)–positive women. METHODS All women screened and triaged for cervical cancer at four government health facilities in Honduras who were eligible for ablative treatment were enrolled and treated with thermal ablation. Women with confirmed CIN2-3 and a subset of women with CIN1/normal diagnoses at baseline were evaluated at 12 months. Follow-up procedures included HPV testing (careHPV), VIA, directed biopsy (if VIA-positive), and Papanicolaou test (if HPV positive, VIA negative). Outcomes at 1 year included histologic or cytologic assessment of CIN lesions among those with any abnormal test. RESULTS Among the 319 women treated with thermal ablation, baseline histologic diagnoses were available for 317. Two (0.6%) had invasive cancer, 36 (11.4%) had CIN3, 40 (12.6%) had CIN2, and 239 (75.4%) had CIN1/normal histology. Among the 127 women eligible for follow-up, 118 (92.9%) completed all study procedures at 1 year. Overall, 98 (83.1%) had no evidence of CIN2-3 or persistent low-grade infection, 13 (11.2%) had CIN1/atypical squamous cells of undetermined significance, six (5.1%) had CIN2/high-grade squamous intraepithelial lesion, and 1 (0.8%) had a persistent CIN3. No adverse events associated with thermal ablation at 1 year were registered. CONCLUSION A high proportion of women had no evidence of CIN2-3 at 1 year after thermal ablation treatment. Thermal ablation is an alternative to cryotherapy that may facilitate greater treatment coverage and prevent unnecessary deaths from cervical cancer.
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Affiliation(s)
| | | | - Manuel A Sandoval
- Asociación Hondureña de Planificación de Familia (ASHONPLAFA), Tegucigalpa, Honduras
| | | | - Doris M Rodriguez
- Asociación Hondureña de Planificación de Familia (ASHONPLAFA), Tegucigalpa, Honduras
| | - Jose Saul Lobo
- Asociación Hondureña de Planificación de Familia (ASHONPLAFA), Tegucigalpa, Honduras
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Papoutsis D, Underwood M, Williams J, Parry-Smith W, Panikkar J. Expansile Endocervical Crypt Involvement by CIN2 - 3 as a Risk Factor for High Grade Cytology Recurrence After Cold Coagulation Cervical Treatment. Geburtshilfe Frauenheilkd 2020; 80:941-948. [PMID: 32905285 PMCID: PMC7467802 DOI: 10.1055/a-1202-2157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 06/17/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction
To determine whether expansile endocervical crypt involvement (ECI) on pretreatment cervical punch biopsies is a risk factor for high grade cytology recurrence in women following cold coagulation for cervical intraepithelial neoplasia (CIN).
Materials and Methods
This was a secondary analysis on the results of an observational study of women who had a single cold coagulation cervical treatment between 2001 – 2011 and who were followed up for cytology recurrence. Women with a previous cervical treatment were excluded.
Results
559 women were identified with a mean age of 28.7 ± 6.2 years. Expansile and non-expansile ECI were identified in 5.4 and 4.3% of women, respectively. The proportion of women with high grade cytology recurrence was 10% for those with expansile ECI and 2.3% for those without. Multivariate analysis showed that women with expansile ECI when compared to those without, had a four-fold greater risk for high grade cytology recurrence (HR = 4.22; 95% CI: 1.10 – 16.29, p = 0.036). There was no significant association found between non-expansile ECI and overall or high grade cytology recurrence. The increased biopsy depth and the CIN3 grade of pretreatment cervical punch biopsies were significantly associated with greater odds for the detection of expansile ECI. We calculated that the optimal-cut off of pretreatment cervical punch biopsy depth for the detection of expansile ECI was 4 mm (sensitivity: 73.3%; specificity: 55.1%).
Conclusions
Expansile ECI is a risk factor that increases the likelihood of high grade cytology recurrence following cold coagulation. Deeper pretreatment cervical punch biopsies need to be taken so as not to miss expansile ECI prior to ablative treatment.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.,Department of Health Sciences, University of Western Macedonia, Koila, Kozani, Greece
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Joanna Williams
- Department of Histopathology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
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de Fouw M, Oosting RM, Eijkel BIM, van Altena PFJ, Peters AAW, Dankelman J, Beltman JJ. Comparison of the tissue interaction between thermal ablation and cryotherapy as treatment for cervical precancerous lesions in an ex-vivo model. HEALTH AND TECHNOLOGY 2020. [DOI: 10.1007/s12553-020-00459-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Cubie HA, Campbell C. Cervical cancer screening - The challenges of complete pathways of care in low-income countries: Focus on Malawi. ACTA ACUST UNITED AC 2020; 16:1745506520914804. [PMID: 32364058 PMCID: PMC7225784 DOI: 10.1177/1745506520914804] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.
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Affiliation(s)
- Heather A Cubie
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Christine Campbell
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
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Salcedo MP, Oliveira C, Andrade V, Mariano AAN, Changule D, Rangeiro R, Monteiro ECS, Baker E, Phoolcharoen N, Varon ML, Thomas JP, Castle PE, Fregnani JHTG, Schmeler KM, Lorenzoni C. The Capulana study: a prospective evaluation of cervical cancer screening using human papillomavirus testing in Mozambique. Int J Gynecol Cancer 2020; 30:1292-1297. [PMID: 32737122 DOI: 10.1136/ijgc-2020-001643] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement cervical cancer screening with human papillomavirus (HPV) testing, with navigation of women with abnormal results to appropriate diagnostic and treatment services. METHODS We prospectively enrolled women aged 30-49 years living in Maputo, Mozambique, from April 2018 to September 2019. All participants underwent a pelvic examination by a nurse, and a cervical sample was collected and tested for HPV using the careHPV test (Qiagen, Gaithersburg, Maryland, USA). HPV positive women were referred for cryotherapy or, if ineligible for cryotherapy, a loop electrosurgical excision procedure. Women with findings concerning for cancer were referred to the gynecologic oncology service. RESULTS Participants (n=898) had a median age of 38 years and 20.3% were women living with the human immunodeficiency virus. HPV positivity was 23.7% (95% confidence interval 21.0% to 26.6%); women living with human immunodeficiency virus were twice as likely to test positive for HPV as human immunodeficiency virus negative women (39.2% vs 19.9%, p<0.001). Most HPV positive women (194 of 213, 91.1%) completed all steps of their diagnostic work-up and treatment. Treatment included cryotherapy (n=158, 77.5%), loop electrosurgical excision procedure (n=30, 14.7%), or referral to a gynecologist or gynecologic oncologist (n=5, 2.5%). Of eight invasive cervical cancers, 5 (2.8%) were diagnosed in women living with human immunodeficiency virus and 3 (0.4%) in human immunodeficiency virus negative women (p=0.01). CONCLUSION Cervical cancer screening with HPV testing, including appropriate follow-up and treatment, was feasible in our study cohort in Mozambique. Women living with human immunodeficiency virus appear to be at a significantly higher risk for HPV infection and the development of invasive cervical cancer than human immunodeficiency virus negative women.
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Affiliation(s)
- Mila P Salcedo
- The Department of Obstetrics and Gynecology, Federal University of Health Science of Porto Alegre/Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil.,Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cristina Oliveira
- Life and Health Siences Research Institute (ICVS), University of Minho, Braga, Portugal.,Molecular Oncology Research Center, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
| | - Viviane Andrade
- Research Support Center of Teaching and Research Institute, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
| | | | - Dércia Changule
- Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
| | | | | | - Ellen Baker
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Melissa L Varon
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph P Thomas
- Department of Oncology Care and Research Information Systems, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Kathleen M Schmeler
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesaltina Lorenzoni
- Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique.,Pathology Department, Hospital Central de Maputo, Maputo, Mozambique
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Holme F, Jeronimo J, Maldonado F, Camel C, Sandoval M, Martinez-Granera B, Montenegro M, Figueroa J, Slavkovsky R, Thomson KA, de Sanjose S. Introduction of HPV testing for cervical cancer screening in Central America: The Scale-Up project. Prev Med 2020; 135:106076. [PMID: 32247010 PMCID: PMC7218710 DOI: 10.1016/j.ypmed.2020.106076] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/30/2020] [Accepted: 03/28/2020] [Indexed: 01/02/2023]
Abstract
The Scale-Up project introduced vaginal self-sampling and low-cost human papillomavirus (HPV) testing as the primary approach for cervical cancer screening in selected public health centers in Guatemala, Honduras, and Nicaragua. We evaluate the country-specific accomplishments in screening: target-coverage, triage, and treatment. Between 2015 and 2018, cervical cancer screening was offered to women at least 30 years of age. Triage of HPV-positive women was based on visual inspection with acetic acid or Pap. Aggregated data included total women screened, use of self-sampling, age, time elapsed since last screening, HPV results, triage tests, triage results, and treatment. A total of 231,741 women were screened for HPV, representing 85.8% of the target populations within the project. HPV positivity was lower in Guatemala (12.4%) compared to Honduras and Nicaragua (14.5% and 14.2%, respectively, p < 0.05). A follow-up triage test was completed for 84.2%, 85.8%, and 50.1% of HPV-positive women in Guatemala, Nicaragua, and Honduras, respectively. Of those with a positive triage test, 84.7%, 67.1%, and 58.8% were treated in Guatemala, Nicaragua, and Honduras, respectively. First-time screening was highest in Nicaragua (55.8%) where self-sampling was also widely used (97.1%). The Scale-Up project demonstrated that large-scale cervical cancer screening and treatment intervention in a high-burden, low-resource setting can be achieved. Self-sampling and ablative treatment were key to the project's achievements. Data monitoring, loss to follow-up, and triage methods of screen- positive women remain critical to full success.
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Affiliation(s)
| | | | | | - Claudia Camel
- Ministry of Public Health and Social Assistance, Guatemala City, Guatemala
| | - Manuel Sandoval
- Asociación Hondureña de Planificación de Familia, Tegucigalpa, Honduras.
| | | | - Mirna Montenegro
- Instancia por la Salud y el Desarrollo de las Mujeres, Guatemala City, Guatemala
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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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Holme F, Maldonado F, Martinez-Granera OB, Rodriguez JM, Almendarez J, Slavkovsky R, Bansil P, Thomson KA, Jeronimo J, de Sanjose S. HPV-based cervical cancer screening in Nicaragua: from testing to treatment. BMC Public Health 2020; 20:495. [PMID: 32295562 PMCID: PMC7161152 DOI: 10.1186/s12889-020-08601-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/26/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In Nicaragua, cervical cancer is the leading cause of cancer death among women. Human papillomavirus (HPV) testing, primarily using self-sampling, was introduced between 2014 and 2018 in three provinces. We analyzed data from the HPV screening program with the goal of describing key characteristics including reach, HPV prevalence, triage and treatment, and factors associated with follow-up completion. METHODS We analyzed individual-level data from routinely collected forms for women attending HPV-based cervical cancer screening. HPV-positive women were triaged with Pap or visual inspection with acetic acid (VIA) prior to treatment. Logistic regression was used to identify factors associated with receiving triage and treatment; analyses were adjusted for province, age, and self- vs. provider-collected sampling. RESULTS Forty-four thousand six hundred thirty-five women were screened with HPV testing; 96.6% of women used self-sampling. Six thousand seven hundred seventy-six women were HPV positive (15.2%), 54.0% of screen-positive women received triage, and 53.1% of triage-positive women were treated, primarily with cryotherapy. If women lost at triage are included, the overall treatment percentage was 27.8%. Province and provider sampling were significantly associated with completing triage. Province and triage type were significantly associated with receiving treatment. The odds of receiving treatment after Pap triage as compared to VIA was significantly lower (aOR: 0.05, 95% CI: 0.04-0.08, p < 0.001), and the relative proportion of women receiving treatment after Pap triage versus VIA was 0.29. CONCLUSIONS Introduction of HPV testing resulted in a substantial number of women screened, and acceptance of self-sampling was high. Management of screen-positive women remained a challenge, particularly with Pap triage. Our results can inform other developing countries as they work to reach World Health Organization (WHO) elimination targets.
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Affiliation(s)
- Francesca Holme
- PATH, Department of Sexual & Reproductive Health, 2201 Westlake Ave., Suite 200, Seattle, WA, 98101, USA.
| | - Francisco Maldonado
- Movicancer, Rpto. Las Palmas, del Semáforo "El Guanacaste" (Walmart), 200 mts. al Lago, 175 mts. al Este., Casa, #1108, Managua, Nicaragua
| | - Orlando B Martinez-Granera
- Movicancer, Rpto. Las Palmas, del Semáforo "El Guanacaste" (Walmart), 200 mts. al Lago, 175 mts. al Este., Casa, #1108, Managua, Nicaragua
| | - Jose Maria Rodriguez
- Movicancer, Rpto. Las Palmas, del Semáforo "El Guanacaste" (Walmart), 200 mts. al Lago, 175 mts. al Este., Casa, #1108, Managua, Nicaragua
| | - Juan Almendarez
- Movicancer, Rpto. Las Palmas, del Semáforo "El Guanacaste" (Walmart), 200 mts. al Lago, 175 mts. al Este., Casa, #1108, Managua, Nicaragua
| | - Rose Slavkovsky
- PATH, Department of Sexual & Reproductive Health, 2201 Westlake Ave., Suite 200, Seattle, WA, 98101, USA
| | - Pooja Bansil
- PATH, Department of Sexual & Reproductive Health, 2201 Westlake Ave., Suite 200, Seattle, WA, 98101, USA
| | - Kerry A Thomson
- PATH, Department of Sexual & Reproductive Health, 2201 Westlake Ave., Suite 200, Seattle, WA, 98101, USA
| | | | - Silvia de Sanjose
- PATH, Department of Sexual & Reproductive Health, 2201 Westlake Ave., Suite 200, Seattle, WA, 98101, USA
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48
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Affiliation(s)
- Vivien Davis Tsu
- Department of Global Health, University of Washington, Seattle, WA 98195, USA.
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49
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Pinder LF, Parham GP, Basu P, Muwonge R, Lucas E, Nyambe N, Sauvaget C, Mwanahamuntu MH, Sankaranarayanan R, Prendiville W. Thermal ablation versus cryotherapy or loop excision to treat women positive for cervical precancer on visual inspection with acetic acid test: pilot phase of a randomised controlled trial. Lancet Oncol 2020; 21:175-184. [PMID: 31734069 PMCID: PMC6946855 DOI: 10.1016/s1470-2045(19)30635-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cryotherapy is standard practice for treating patients with cervical precancer in see-and-treat programmes in low-income and middle-income countries (LMICs). Because of logistical difficulties with cryotherapy (eg, the necessity, costs, and supply chain difficulties of refrigerant gas; equipment failure; and treatment duration >10 min), a battery-operated thermal ablator that is lightweight and portable has been developed. We aimed to compare thermal ablation using the new device with cryotherapy. METHODS We report the pilot phase of a randomised controlled trial in routine screen-and-treat clinics providing cervical screening using visual inspection with acetic acid (VIA) in Lusaka, Zambia. We recruited non-pregnant women, aged 25 years or older, who were eligible for ablative therapy. We randomly assigned participants (1:1:1) to thermal ablation, cryotherapy, or large loop excision of the transformation zone (LLETZ), using computer-generated allocation. The randomisation was concealed but the nurses providing treatment and the participants were unmasked. Thermal ablation was achieved using the Liger thermal ablator (using 1-5 overlapping applications of the probe heated to 100°C, each application lasting for 40 s), cryotherapy was carried out using the double-freeze technique (freeze for 3 min, thaw for 5 min, and freeze again for 3 min), and LLETZ (using a large loop driven by an electro-surgical unit to excise the transformation zone) was done under local anaesthesia. The primary endpoint was treatment success, defined as either human papillomavirus (HPV) type-specific clearance among participants who were positive for the same HPV type at baseline, or a negative VIA test at 6-month follow-up, if the baseline HPV test was negative. Per protocol analyses were done. Enrolment for the full trial is ongoing. Here, we present findings from a prespecified pilot phase of the full trial. The final analysis of the full trial will assess non-inferiority of the groups for the primary efficacy endpoint. The study is registered with ClinicalTrials.gov, number NCT02956239. FINDINGS Between Aug 2, 2017, and Jan 15, 2019, 750 participants were randomly assigned (250 per group). 206 (84%) participants in the cryotherapy group, 197 (81%) in the thermal ablation group, and 204 (84%) in the LLETZ group attended the 6-month follow-up examination. Treatment success was reported in 120 (60%) of 200 participants in the cryotherapy group, 123 (64%) of 192 in the thermal ablation group, and 134 (67%) of 199 in the LLETZ group (p=0·31). Few participants complained of moderate to severe pain in any group immediately after the procedure (six [2%] of 250 in the cryotherapy group, four [2%] of 250 in the thermal ablation group, and five [2%] of 250 in the LLETZ group) and 2 weeks after the procedure (one [<1%] of 241 in the cryotherapy group, none of 242 in the thermal ablation group, and two [<1%] of 237 in the LLETZ group). None of the participants reported any complication requiring medical consultation or admission to hospital. INTERPRETATION Results from this pilot study preliminarily suggest that thermal ablation has similar treatment success to cryotherapy, without the practical disadvantages of providing cryotherapy in an LMIC. However, the study was not powered to establish the similarity between the techniques, and results from the ongoing randomised controlled trial are need to confirm these results. FUNDING US National Institutes of Health.
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Affiliation(s)
- Leeya F Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA; Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Groesbeck P Parham
- Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France.
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | - Eric Lucas
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | | | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | - Mulindi H Mwanahamuntu
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, University of Zambia, Lusaka, Zambia
| | - Rengaswamy Sankaranarayanan
- Research Triangle Institute, International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India
| | - Walter Prendiville
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
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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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