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Hategeka C, Adu P, Desloge A, Marten R, Shao R, Tian M, Wei T, Kruk ME. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review. PLoS Med 2022; 19:e1004055. [PMID: 35877677 PMCID: PMC9359585 DOI: 10.1371/journal.pmed.1004055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/08/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Prince Adu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allissa Desloge
- School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | | | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ting Wei
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
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Prabhu M, Riley LE. Challenges in Interpreting the Ob/Gyn Literature: Studies of Screening. Clin Obstet Gynecol 2022; 65:244-251. [PMID: 35354158 DOI: 10.1097/grf.0000000000000704] [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: 11/26/2022]
Abstract
Screening tests are critical to patient care. Screening tests must meet ten criteria established by the World Health Organization in order to be considered effective. Common types of studies on screening tests include those that establish test characteristics, such as sensitivity, specificity, positive predictive value, and negative predictive value, as well as cost-effective analyses. In this paper, we review the criteria for effective screening tests, and discuss the strengths and pitfalls of common study designs evaluating screening tests.
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Affiliation(s)
- Malavika Prabhu
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, New York
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Johnson LG, Armstrong A, Joyce CM, Teitelman AM, Buttenheim AM. Implementation strategies to improve cervical cancer prevention in sub-Saharan Africa: a systematic review. Implement Sci 2018; 13:28. [PMID: 29426344 PMCID: PMC5807829 DOI: 10.1186/s13012-018-0718-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/29/2018] [Indexed: 12/23/2022] Open
Abstract
Background Developed countries, such as the USA, have achieved significant decreases in cervical cancer burden since the introduction of Pap smear-based programs in the 1960s. Due to implementation barriers and limited resources, many countries in sub-Saharan Africa (SSA) have been unable to attain such reductions. The purpose of this review is to evaluate implementation strategies used to improve the uptake and sustainability of cervical cancer prevention programs in SSA. Methods A reviewer (LJ) independently searched PubMed, Ovid/MEDLINE, Scopus, and Web of Science databases for relevant articles with the following search limits: English language, peer reviewed, and published between 1996 and 2017. The 4575 search results were screened for eligibility (CJ, LJ) to identify original research that empirically evaluated or tested implementation strategies to improve cervical cancer prevention in SSA. Fifty-three articles met criteria for inclusion in the final review. AA, CJ, and LJ abstracted the included articles for implementation-related content and evaluated them for risk of bias according to study design with the National Heart, Lung, and Blood Institute’s (NHLBI) Quality Assessment Tools. Results were reported according to PRISMA guidelines. Results The 53 included studies are well represented among all sub-Saharan regions: South (n = 16, 30.2%), West (n = 16, 30.2%), East (n = 14, 26.4%), and Middle (n = 7, 13.2%). There are 34 cross-sectional studies (64.2%), 10 pre-posttests (18.9%), 8 randomized control trials (15.1%), and one nonrandomized control trial (1.9%). Most studies are “fair” quality (n = 22, 41.5%). Visual inspection with acetic acid (VIA) (n = 19, 35.8%) was used as the main prevention method more frequently than HPV DNA/mRNA testing (n = 15, 28.3%), Pap smear (n = 13, 24.5%), and HPV vaccine (n = 9, 17.0%). Effectiveness of strategies to improve program implementation was measured using implementation outcomes of penetration (n = 33, 62.3%), acceptability (n = 15, 28.3%), fidelity (n = 14, 26.4%), feasibility (n = 8, 15.1%), adoption (n = 6, 11.3%), sustainability (n = 2, 3.8%), and cost (n = 1, 1.9%). Education strategies (n = 38, 71.7%) were used most often but have shown limited effectiveness. Conclusion This systematic review highlights the need to diversify strategies that are used to improve implementation for cervical cancer prevention programs. While education is important, implementation science literature reveals that education is not as effective in generating change. There is a need for additional organizational support to further incentivize and sustain improvements in implementation. Electronic supplementary material The online version of this article (10.1186/s13012-018-0718-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lauren G Johnson
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
| | - Allison Armstrong
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline M Joyce
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Teitelman
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Greenwald ZR, El-Zein M, Bouten S, Ensha H, Vazquez FL, Franco EL. Mobile Screening Units for the Early Detection of Cancer: A Systematic Review. Cancer Epidemiol Biomarkers Prev 2017; 26:1679-1694. [DOI: 10.1158/1055-9965.epi-17-0454] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/09/2017] [Accepted: 09/27/2017] [Indexed: 11/16/2022] Open
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Thomas V, Sudrania I, Sebastian A, Thomas A, Chandy R, Kumar RM, Peedicayil A. Management of Abnormal Pap Smears in a Tertiary Care Hospital. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2015. [DOI: 10.1007/s40944-015-0012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ebisch RMF, Rovers MM, Bosgraaf RP, van der Pluijm-Schouten HW, Melchers WJG, van den Akker PAJ, Massuger LFAG, Bekkers RLM. Evidence supporting see-and-treat management of cervical intraepithelial neoplasia: a systematic review and meta-analysis. BJOG 2015; 123:59-66. [DOI: 10.1111/1471-0528.13530] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2015] [Indexed: 11/28/2022]
Affiliation(s)
- RMF Ebisch
- Department of Obstetrics and Gynaecology; Radboud University Medical Center; Nijmegen the Netherlands
| | - MM Rovers
- Department of Health Evidence; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Operating Rooms; Radboud University Medical Center; Nijmegen the Netherlands
| | - RP Bosgraaf
- Department of Obstetrics and Gynaecology; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Obstetrics and Gynaecology; Jeroen Bosch Hospital; 's-Hertogenbosch the Netherlands
| | | | - WJG Melchers
- Department of Medical Microbiology; Radboud University Medical Center; Nijmegen the Netherlands
| | - PAJ van den Akker
- Department of Obstetrics and Gynaecology; Radboud University Medical Center; Nijmegen the Netherlands
| | - LFAG Massuger
- Department of Obstetrics and Gynaecology; Radboud University Medical Center; Nijmegen the Netherlands
| | - RLM Bekkers
- Department of Obstetrics and Gynaecology; Radboud University Medical Center; Nijmegen the Netherlands
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Fokom-Domgue J, Combescure C, Fokom-Defo V, Tebeu PM, Vassilakos P, Kengne AP, Petignat P. Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies. BMJ 2015; 351:h3084. [PMID: 26142020 PMCID: PMC4490835 DOI: 10.1136/bmj.h3084] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess and compare the accuracy of visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) testing as alternative standalone methods for primary cervical cancer screening in sub-Saharan Africa. DESIGN Systematic review and meta-analysis of diagnostic test accuracy studies. DATA SOURCES Systematic searches of multiple databases including Medline, Embase, and Scopus for studies published between January 1994 and June 2014. REVIEW METHODS Inclusion criteria for studies were: alternative methods to cytology used as a standalone test for primary screening; study population not at particular risk of cervical cancer (excluding studies focusing on HIV positive women or women with gynaecological symptoms); women screened by nurses; reference test (colposcopy and directed biopsies) performed at least in women with positive screening results. Two reviewers independently screened studies for eligibility and extracted data for inclusion, and evaluated study quality using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) checklist. Primary outcomes were absolute accuracy measures (sensitivity and specificity) of screening tests to detect cervical intraepithelial neoplasia grade 2 or worse (CIN2+). RESULTS 15 studies of moderate quality were included (n=61,381 for VIA, n=46,435 for VILI, n=11,322 for HPV testing). Prevalence of CIN2+ did not vary by screening test and ranged from 2.3% (95% confidence interval 1.5% to 3.3%) in VILI studies to 4.9% (2.7% to 7.8%) in HPV testing studies. Positivity rates of VILI, VIA, and HPV testing were 16.5% (9.8% to 24.7%), 16.8% (11.0% to 23.6%), and 25.8% (17.4% to 35.3%), respectively. Pooled sensitivity was higher for VILI (95.1%; 90.1% to 97.7%) than VIA (82.4%; 76.3% to 87.3%) in studies where the reference test was performed in all women (P<0.001). Pooled specificity of VILI and VIA were similar (87.2% (78.1% to 92.8%) v 87.4% (77.1% to 93.4%); P=0.85). Pooled sensitivity and specificity were similar for HPV testing versus VIA (both P ≥ 0.23) and versus VILI (both P ≥ 0.16). Accuracy of VIA and VILI increased with sample size and time period. CONCLUSIONS For primary screening of cervical cancer in sub-Saharan Africa, VILI is a simple and affordable alternative to cytology that demonstrates higher sensitivity than VIA. Implementation studies are needed to assess the effect of these screening strategies on the incidence and outcomes of cervical cancer in the region.
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Affiliation(s)
- Joël Fokom-Domgue
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, 1211 Geneva 14, Switzerland
| | | | - Victoire Fokom-Defo
- Division of Infectious and Chronic Diseases, Department of Internal Medicine, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Pierre Marie Tebeu
- Department of Gynecology and Obstetrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - André Pascal Kengne
- South African Medical Research Council and University of Cape Town, Cape Town, South Africa
| | - Patrick Petignat
- Division of Gynecology, Department of Gynecology and Obstetrics, Geneva University Hospitals, 1211 Geneva 14, Switzerland
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See-and-treat surgery for facial skin cancer. Br J Oral Maxillofac Surg 2014; 52:598-602. [DOI: 10.1016/j.bjoms.2014.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 04/06/2014] [Indexed: 11/22/2022]
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Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control. J Cancer Epidemiol 2011; 2011:794861. [PMID: 21559068 PMCID: PMC3083000 DOI: 10.1155/2011/794861] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 01/17/2011] [Indexed: 01/20/2023] Open
Abstract
This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world.
The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.
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Mauad EC, Nicolau SM, Gomes UA, da Costa Vieira RA, de Castro Mattos JS, Longatto-Filho A, Baracat EC. Can mobile units improve the strategies for cervical cancer prevention? Diagn Cytopathol 2011; 38:727-30. [PMID: 20014304 DOI: 10.1002/dc.21287] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Cervical cancer is a serious public health problem in women in developing countries because of absence or ineffectiveness of screening programs. Several biases to access medical care and inequity of public health system in a continental country like Brazil limit the implementation of adequate programs to appropriately prevent the cervical cancer. Therefore, the aim of this study was to evaluate the results of applying the mobile unit (MU) for cervical cancer screening. From May 2003 to May 2004, a cervical cancer screening was offered to women aged 20-69 years, residing in 19 municipal districts of the Barretos county region, in São Paulo. Out of the 9,560 examination available, 2,964 (31%) women underwent screening. The medium distance traveled by the MU was 45 km. The medium time spent by women in the MU for completion of the questionnaire and doing the exam was 20 minutes. It was observed that 17.0% of women screened had never had the test or had not had it repeated within the last 3 years. The negative response was more common among women aged 20 to 29 years and 60 to 69 years and among women with less schooling and lower socio-economic income (P < 0.05). MU can significantly overcome the chronic deficiency of public health system accessibility offering opportunity to these women to participate in screening programs.
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Battaglia TA, Santana MC, Bak S, Gokhale M, Lash TL, Ash AS, Kalish R, Tringale S, Taylor JO, Freund KM. Predictors of timely follow-up after abnormal cancer screening among women seeking care at urban community health centers. Cancer 2010; 116:913-21. [PMID: 20052731 PMCID: PMC2819638 DOI: 10.1002/cncr.24851] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We sought to measure time and identify predictors of timely follow-up among a cohort of racially/ethnically diverse inner city women with breast and cervical cancer screening abnormalities. METHODS Eligible women had an abnormality detected on a mammogram or Papanicolaou (Pap) test between January 2004 and December 2005 in 1 of 6 community health centers in Boston, Massachusetts. Retrospective chart review allowed us to measure time to diagnostic resolution. We used Cox proportional hazards models to develop predictive models for timely resolution (defined as definitive diagnostic services completed within 180 days from index abnormality). RESULTS Among 523 women with mammography abnormalities and 474 women with Pap test abnormalities, >90% achieved diagnostic resolution within 12 months. Median time to resolution was longer for Pap test than for mammography abnormalities (85 vs 27 days). Site of care, rather than any sociodemographic characteristic of individuals, including race/ethnicity, was the only significant predictor of timely follow-up for both mammogram and Pap test abnormalities. CONCLUSIONS Site-specific community-based interventions may be the most effective interventions to reduce cancer health disparities when addressing the needs of underserved populations.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Department of Medicine, and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA 02118, USA.
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Monteiro ACS, Russomano F, Reis A, Camargo MJD, Fialho SA, Tristão MA, Soares T. Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix. Rev Saude Publica 2009; 43:846-50. [DOI: 10.1590/s0034-89102009000500014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Accepted: 04/28/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS: A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS: Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS: The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.
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Affiliation(s)
| | | | - Aldo Reis
- Faculdade de Medicina de Campos, Brasil
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Safaeian M, Solomon D, Castle PE. Cervical cancer prevention--cervical screening: science in evolution. Obstet Gynecol Clin North Am 2008; 34:739-60, ix. [PMID: 18061867 DOI: 10.1016/j.ogc.2007.09.004] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The incidence and mortality of cervical cancer in the United States has declined by more than 70% since the 1950s. This decline is attributed mainly to the introduction of Papanicolaou's test in the 1940s. Cervical cancer, however, remains the second most frequent of all female malignancies worldwide, with 80% of the cases occurring in resource-poor countries. This disparity is attributed primarily to the lack of screening and treatment of precancerous lesions. This article describes the traditional methods of screening for cervical cancer and innovative methods that might help overcome financial and cultural barriers to more widespread screening.
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Affiliation(s)
- Mahboobeh Safaeian
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health/DHHS, 6120 Executive Blvd., Rockville, MD 20852, USA.
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Hearp ML, Locante AM, Ben-Rubin M, Dietrich R, David O. Validity of sampling error as a cause of noncorrelation. Cancer 2007; 111:275-9. [PMID: 17665495 DOI: 10.1002/cncr.22945] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sampling error is a common explanation of noncorrelation in women whose Papanicolaou (Pap) tests show high-grade intraepithelial lesions (HSIL) but whose follow-up cervical biopsies show only cervical intraepithelial neoplasia (CIN) 1, koilocytosis, or reactive/inflammatory changes. The purpose of this study was to demonstrate the validity of sampling error in this setting by determining the proportion of negative colposcopic cervical biopsies in women with HSIL who subsequently undergo cone/loop electrode excision procedure (LEEP) biopsies or repeat cervical biopsies that confirm the diagnosis of high-grade CIN (HGCIN). METHODS In all, 368 cases of HSIL were retrieved from the computerized database from January 1, 2003 to December 31, 2005. Follow-up was obtained as part of routine quality assurance/quality control activities including cytologic-histologic correlation. RESULTS A total of 368 HSIL Pap diagnoses were retrieved. Of the 254 cases that were followed up by cervical biopsy, 146 showed HGCIN in the biopsy. Of the remaining 108 patients whose cervical biopsies failed to demonstrate HGCIN, 47 had a subsequent procedure, either cone/LEEP, cervical biopsy, or repeat Pap test. Cone biopsy/LEEP was performed in 34 cases (72.3%) with a diagnosis of HGCIN in 19. Repeat cervical biopsy was performed in 9 cases (19.1%) with HGCIN diagnosed in 5. Repeat Pap test was performed in 4 cases (8.5%) with HSIL diagnosed in 2. CONCLUSIONS In the population of women with HSIL by Pap test followed up by cervical biopsy with or without subsequent cone/LEEP, there was a discordant cervical biopsy rate for HGCIN of 43%. In the subgroup of women with HSIL by Pap test followed up by cervical biopsy and subsequent cone/LEEP or repeat cervical biopsy, the proportion of women with negative colposcopic cervical biopsy and subsequent histology-proven HGCIN was 56%. These figures justify sampling error as a valid cause of noncorrelation in women with HSIL followed up by cervical biopsy alone.
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Affiliation(s)
- Matthew L Hearp
- Department of Pathology, University of Illinois Medical Center, Chicago, Illinois 60612, USA
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Balasubramani L, Orbell S, Hagger M, Brown V, Tidy J. Do women with high-grade cervical intraepithelial neoplasia prefer a see and treat option in colposcopy? BJOG 2006; 114:39-45. [PMID: 17233858 DOI: 10.1111/j.1471-0528.2006.01160.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare women's experiences of either see and treat (ST) or defer and treat (DT) at first visit to colposcopy following abnormal cytology. DESIGN A prospective postal questionnaire survey. SETTING Colposcopy clinics of a University Hospital. SAMPLE A total of 272 women with high-grade cervical intraepithelial neoplasia (CIN) referred to colposcopy. METHODS A total of 136 women receiving ST and a matched sample of women receiving DT (N = 136) were sent a postal questionnaire 7 days after first appointment at colposcopy to assess evaluations of their experience, psychological distress and relief. Subsequent appointment keeping was extracted from medical records. MAIN OUTCOME MEASURES Anxiety and subsequent behaviour. RESULTS Women undergoing ST were significantly less anxious and more relieved than those undergoing DT. They also evaluated their first appointment as more motivationally congruent. While women undergoing ST were less likely than DTs to keep their second appointment, there was no overall difference in did not attend (DNA) rates at 15-month follow up. CONCLUSIONS ST is psychologically beneficial and may be preferred by women with CIN2/3.
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Affiliation(s)
- L Balasubramani
- Academic Unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, UK
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Dainty LA, Elkas JC, Rose GS, Zahn CM. Controversial topics in abnormal cervical cytology: "see and treat". Clin Obstet Gynecol 2005; 48:193-201. [PMID: 15725871 DOI: 10.1097/01.grf.0000151582.70615.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Louis A Dainty
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Walter Reed Army Medical Center, Washington, DC 20307, USA.
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Cárdenas-Turanzas M, Follen M, Benedet JL, Cantor SB. See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions. Lancet Oncol 2005; 6:43-50. [PMID: 15629275 DOI: 10.1016/s1470-2045(04)01712-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1.2-83.3% for low-grade squamous intraepithelial lesions (SIL) and to be 13.3-83.3% for high-grade SIL. Range of overtreatment narrowed to 4.0-23.5% for those with normal pathology and to 18.0-29.4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.
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Affiliation(s)
- Marylou Cárdenas-Turanzas
- Section of Health Services Research, Department of Biostatistics and Applied Mathematics, University of Texas MD Anderson Cancer Center, Houston, Texas, TX 77030-4009, USA
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Dunn TS, Burke M, Shwayder J. A “See and Treat” Management for High-Grade Squamous Intraepithelial Lesion Pap Smears. J Low Genit Tract Dis 2003; 7:104-6. [PMID: 17051054 DOI: 10.1097/00128360-200304000-00006] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE.: This study evaluates a "see and treat" intervention for high-grade squamous intraepithelial lesions (HSIL) on Pap smears. This is a case control study comparing cost-effectiveness, patient compliance, and pathology obtained from immediate colposcopy and large loop excision of the transformation zone of the uterine cervix. (LLETZ) MATERIALS AND METHODS.: At our institution before the onset of the study, a chart review of 100 patients with HSIL Pap smears was performed. This was the control group. Ninety percent of the patients' in the control group who had HSIL on Pap eventually had LLETZ. The next consecutive 100 women presenting to the clinic who met the same inclusion criteria underwent colposcopy and LLETZ at the same visit and were compared with the control group. Demographics, pathology, compliance, and cost were analyzed. RESULTS.: One hundred patients were treated with one visit colposcopy/LLETZ intervention. Histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2,3 was confirmed in 94% of patients. Two percent of the patients had CIN 1, 1% had no histologic evidence of CIN, and 3% had microinvasive cancer to a depth of 0.5-1.5mm. Cost analysis revealed savings of $35,000 for the institution. Patient compliance was improved with a kept appointment rate of 82%. CONCLUSIONS.: "See and treat" intervention for HSIL Paps was an effective tool. Treating HSIL Paps without a separate visit for colposcopy is a cost-effective management. This method was more convenient for patients with only one disruption of daily schedules.
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Affiliation(s)
- Terry S Dunn
- University of Colorado Health Science Center, Denver Health Medical Center, Denver, CO
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Sankaranarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahé C, Muwonge R, Parkin DM, Cherian J. Determinants of participation of women in a cervical cancer visual screening trial in rural south India. ACTA ACUST UNITED AC 2003; 27:457-65. [PMID: 14642554 DOI: 10.1016/j.cdp.2003.09.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The efficacy of a single round of screening of visual inspection with acetic acid (VIA) on cervical cancer incidence and mortality is investigated in a cluster randomized controlled trial in south India. Women aged 30-59 years in 113 clusters in Dindigul District were randomized to VIA screening by nurses (57 clusters, 48,225 eligible women) and to a control group (56 clusters, 30,167 women). 30,577 (63.4%) eligible women participated in screening. Younger, educated, married, multiparous, low-income women and those who have had tubal sterilization had a higher compliance with screening. Of the 2069 women diagnosed with CIN and invasive cancer, 1498 (72.4%) received treatment. Young women, those who practiced contraception and women with high-grade precursor lesions and invasive cancers were more likely to comply with treatment. In summary, our study indicates that women accept screening with VIA by nurses and a moderate level of compliance with screening and treatment can be reached through appropriate service delivery systems including health education activities, personal invitations, clinics in proximity to the target women, and testing and treatment in the same session. Our results imply that integration of screening activities with primary health services seems to have the potential to replicate most of these service delivery conditions in routine programs.
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Affiliation(s)
- Rengaswamy Sankaranarayanan
- Unit of Descriptive Epidemiology, International Agency for Research on Cancer, 150 cours Albert Thomas, 69008 Lyon, France.
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A Stiff Bristled, Spiral-Shaped Ectocervical Brush. Obstet Gynecol 2002. [DOI: 10.1097/00006250-200212000-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Vasilev SA. Paying for prevention standardizing the measurement of the value of health care interventions. Obstet Gynecol Clin North Am 2002; 29:613-43, v. [PMID: 12509088 DOI: 10.1016/s0889-8545(02)00022-0] [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: 11/23/2022]
Abstract
It is not clear if spending more on tests that enhance the accuracy of Pap smears would lead to a greater reduction in cancer incidence than if the money were spent to include a greater proportion of women in primary screening. The cost effectiveness of tests beyond the Pap smear has not been clearly demonstrated. There is the question of whether cervical cancer incidence can be decreased more by improving the tests for patients who are already screened or by improving access to the unscreened population. Cervical cancer screening represents only one of many public health issues competing for resources. Given that there are choices to be made, the optimal yardstick against which all resource-competing programs are measured should be marginal benefit versus marginal cost.
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Affiliation(s)
- Steven A Vasilev
- Department of Gynecologic Oncology, Kaiser Permanente, 4900 Sunset Boulevard, Building M, Los Angeles, CA 90027, USA.
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Mandelblatt JS, Lawrence WF, Gaffikin L, Limpahayom KK, Lumbiganon P, Warakamin S, King J, Yi B, Ringers P, Blumenthal PD. Costs and benefits of different strategies to screen for cervical cancer in less-developed countries. J Natl Cancer Inst 2002; 94:1469-83. [PMID: 12359856 DOI: 10.1093/jnci/94.19.1469] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND About 80% of cervical cancers occur in less-developed countries. This disproportionate burden of cervical cancer in such countries is due mainly to the lack of well-organized screening programs. Several cervical cancer screening strategies have been proposed as more cost-effective than cytology screening. We compared the costs and benefits of different strategies and their effectiveness in saving lives in a less-developed country. METHODS We used a population-based simulation model to evaluate the incremental societal costs and benefits in Thailand of seven screening techniques, including visual inspection of the cervix after applying acetic acid (VIA), human papillomavirus (HPV) testing, Pap smear, and combinations of screening tests, and examined the discounted costs per year of life saved (LYS). RESULTS Compared with no (i.e., not well-organized) screening, all strategies saved lives, at costs ranging from 121 US dollars to 6720 US dollars per LYS, and reduced mortality, by up to 58%. Comparing each strategy with the next least expensive alternative, VIA performed at 5-year intervals in women of ages 35-55 with immediate treatment if abnormalities are found was the least expensive option and saved the greatest number of lives, with a cost of 517 US dollars per LYS. HPV screening resulted in similar costs and benefits, if the test cost is 5 US dollars and if 90% of women undergo follow-up after an abnormal screen. Cytology (Pap smear) was a reasonable alternative if sensitivity exceeds 80% and if 90% of women undergo follow-up. Compared with no screening, use of a combination of Pap smear and HPV testing at 5-year intervals in women of ages 20-70 could achieve greater than 90% reduction in cervical cancer mortality at a cost of 1683 US dollars per LYS, and VIA could achieve 83% reduction at 524 US dollars per LYS. CONCLUSIONS Well-organized screening programs can reduce cervical cancer mortality in less-developed countries at low costs. These cost-effectiveness data can enhance decision-making about optimal policies for a given setting.
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Affiliation(s)
- Jeanne S Mandelblatt
- Department of Oncology, Georgetown University Medical Center, and the Outcomes Core and Cancer Control Program, Lombardi Cancer Center, Washington, DC 20007, USA.
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Holschneider CH, Felix JC, Satmary W, Johnson MT, Sandweiss LM, Montz FJ. A single-visit cervical carcinoma prevention program offered at an inner city church. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19991215)86:12<2659::aid-cncr10>3.0.co;2-s] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Lazcano-Ponce EC, Moss S, Alonso de Ruíz P, Salmerón Castro J, Hernández Avila M. Cervical cancer screening in developing countries: why is it ineffective? The case of Mexico. Arch Med Res 1999; 30:240-50. [PMID: 10427875 DOI: 10.1016/s0188-0128(99)00006-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mexico established a national cervical cancer-screening program in 1974. Despite the implementation of the program, there was a steady mortality trend of 16 per 100,000 women over 15 years. METHODS A diagnostic procedure of the pitfalls was applied to the following steps of the screening procedure: Pap sampling quality; cytological diagnosis validity; compliance of women; and determinants of non-participation. RESULTS The low effectiveness of screening on cervical cancer is principally due to factors associated with quality and coverage. Pap quality is deficient; 64% of a random sample of specimens lacked endocervical cells. Reading centers presented false negative indices of between 10 and 54%. Women seek screening in a late stage of disease (55% with cervical cancer seek care because they have symptoms). In addition, coverage is low; in women between 15 and 49 years of age in Mexico City, 64.2% have a history of Pap, compared with 30% in rural areas. Knowledge of what the Pap is used for strongly determines the use of screening. In rural areas, only 40% of women are informed about the purpose of the Pap test. CONCLUSIONS A proposal to reorganize Mexico's screening program includes the following five main strategies: (a) increased coverage; (b) improved quality control of how cervical smears are taken; (c) better interpretation of Pap tests; (d) guaranteed treatment for those whose tests show abnormalities, and (e) improved follow-up.
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Affiliation(s)
- E C Lazcano-Ponce
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico.
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Sankaranarayanan R, Shyamalakumary B, Wesley R, Sreedevi Amma N, Parkin DM, Nair MK. Visual inspection with acetic acid in the early detection of cervical cancer and precursors. Int J Cancer 1999; 80:161-3. [PMID: 9935247 DOI: 10.1002/(sici)1097-0215(19990105)80:1<161::aid-ijc28>3.0.co;2-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Salmerón-Castro J, Kazcano Ponce EC, Pérez Cuevas R, del Río Gómez I, Torres Torija I, Hernández Avila M. Proposal to institutionalize criteria and quality standards for cervical cancer screening within a health care system. CAD SAUDE PUBLICA 1998; 14 Suppl 3:67-75. [PMID: 9819465 DOI: 10.1590/s0102-311x1998000700007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The uterine cervix is the most common cancer site for females. Approximately 52,000 new cases occur annually in Latin America, thus the need to improve efficiency and effectiveness of Cervical Cancer Screening Programs (CCSP) is mandatory to decrease the unnecessary suffering women must bear. This paper is addressing essential issues to revamp the CCSP as proposed by the Mexican official norm. A general framework for institutionalizing CCSP is outlined. Furthermore, strategies to strengthen CCSP performance through managerial strategies and quality assurance activities are described. The focus is on the following activities: 1) improving coverage; 2) implementing smear-taking quality control; 3) improving quality in interpretation of Pap test; 4) guaranteeing treatment for women for whom abnormalities are detected; 5) improving follow-up; 6) development of quality control measures and 7) development of monitoring and epidemiological surveillance information systems. Changes within the screening on cervical cancer may be advocated as new technologies present themselves and shortcomings in the existing program appear. It is crucial that these changes should be measured through careful evaluation in order to tally up potential benefits.
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Affiliation(s)
- J Salmerón-Castro
- Unidad de Investigación Epidemiológica y en Servicios de Salud, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social. Avenida Cuahutemoc 330, Unidad de Congresos, Bloque B, 4o piso, México, D. F., C. P. 06720, México
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Sankaranarayanan R, Wesley R, Somanathan T, Dhakad N, Shyamalakumary B, Amma NS, Parkin DM, Nair MK. Visual inspection of the uterine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors. Cancer 1998. [DOI: 10.1002/(sici)1097-0142(19981115)83:10<2150::aid-cncr13>3.0.co;2-0] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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