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Yoneda JY, Teixeira JC, Derchain S, Bragança JF, Zeferino LC, Vale DB. Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women. Eur J Obstet Gynecol Reprod Biol 2023; 280:78-82. [PMID: 36434824 DOI: 10.1016/j.ejogrb.2022.11.016] [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: 09/22/2022] [Revised: 11/02/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions. STUDY DESIGN A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as "overtreatment." Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %). RESULTS No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18-56.02). CONCLUSIONS No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.
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Affiliation(s)
- Juliana Y Yoneda
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil
| | - Julio C Teixeira
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil
| | - Sophie Derchain
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil
| | - Joana F Bragança
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil
| | - Luiz C Zeferino
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil
| | - Diama B Vale
- Department of Obstetrics and Gynecology, University of Campinas, Rua Vital Brazil, 80 - Cidade Universitária, CEP 13083-888 Campinas, Brazil.
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Kiviharju M, Heinonen A, Jakobsson M, Virtanen S, Auvinen E, Kotaniemi-Talonen L, Dillner J, Kyrgiou M, Nieminen P, Aro K, Kalliala I. Overtreatment rate after immediate local excision of suspected cervical intraepithelial neoplasia: A prospective cohort study. Gynecol Oncol 2022; 167:167-173. [PMID: 36153296 DOI: 10.1016/j.ygyno.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The gold standard of cervical intraepithelial neoplasia (CIN) treatment is large loop excision of the transformation zone (LLETZ) after histopathological diagnosis from punch biopsies. In addition, treatment may be appropriate at initial colposcopy. Our objective was to study the applicability of immediate treatment strategy according to clinical parameters. METHODS We conducted a prospective cohort study among patients referred to colposcopy at Helsinki University Hospital, Finland, between January 2014, and September 2018 (ISRCTN10933736). Patients treated with LLETZ, either after biopsies or immediately at initial colposcopy, were included. The main outcome measure was overtreatment (OT) rate defined as normal or low-grade histopathological findings in LLETZ specimen within both treatment groups. RESULTS A total of 572 patients treated with LLETZ were included: 360 treated after biopsies and 212 treated immediately at initial colposcopy. When LLETZ was performed immediately after high-grade referral cytology and with colposcopic impression of high-grade disease, the overtreatment (OT) rate was 10.0% (95% CI 9.10 to 17.2), whereas when LLETZ was done after biopsy-confirmed high-grade lesions, the OT rate was 18.9% (95% CI 14.7 to 23.7), resulting in risk difference (RD) -8.91% (95% CI -16.0 to -1.82). Among HPV16/18 positive patients the OT rate was 8.22% (95% CI 3.08 to 17.0) for immediate treatment, resulting in RD of -10.7% (95% CI -18.3 to -3.04) compared to LLETZ after biopsies. CONCLUSIONS Immediate LLETZ does not result in overtreatment when applied on selected cases, especially after high-grade referral cytology and when high-grade lesion is also colposcopically suspected.
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Affiliation(s)
- Mari Kiviharju
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Annu Heinonen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Maija Jakobsson
- Department of Obstetrics and Gynecology, Hyvinkää Hospital, HUCH and University of Helsinki, 05850 Hyvinkää, Finland
| | - Seppo Virtanen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki, Helsinki University Hospital, 00014 Helsinki, Finland
| | - Laura Kotaniemi-Talonen
- Department of Obstetrics and Gynecology, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Finland
| | | | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction - Surgery & Cancer, Faculty of Medicine, Imperial College London, W120NN, London, UK
| | - Pekka Nieminen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland
| | - Karoliina Aro
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland.
| | - Ilkka Kalliala
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00029 Helsinki, Finland; Department of Metabolism, Digestion and Reproduction - Surgery & Cancer, Faculty of Medicine, Imperial College London, W120NN, London, UK
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Bonow MP, Collaço LM, Percicote AP, Zanine RM. When is There no Benefit in Performing a Biopsy in the Suspicion of Intraepithelial Lesions of the Cervix? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:272-279. [PMID: 35576936 PMCID: PMC9948051 DOI: 10.1055/s-0042-1744212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy. METHODS We performed a retrospective, observational study by analyzing medical records obtained from Hospital de Clínicas do Paraná from February 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed. RESULTS A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively. CONCLUSION There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.
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Affiliation(s)
- Marília Porto Bonow
- Department of Obstetrics and Gynecology, Clinics Hospital of the University of Paraná, Curitiba, PR, Brazil
| | - Luiz Martins Collaço
- Department of Pathology of Clinics Hospital of the University of Paraná, Curitiba, PR, Brazil
| | - Ana Paula Percicote
- Department of Pathology of Clinics Hospital of the University of Paraná, Curitiba, PR, Brazil
| | - Rita Maira Zanine
- Department of Gynecology and Obstetrics, Lower Genital Tract Disease and Colposcopy Sector, Clinics Hospital of the University of Paraná, Curitiba, PR, Brazil
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He W, Sparén P, Fang F, Sengpiel V, Strander B, Czene K. Pregnancy Outcomes in Women With a Prior Cervical Intraepithelial Neoplasia Grade 3 Diagnosis : A Nationwide Population-Based Cohort Study With Sibling Comparison Design. Ann Intern Med 2022; 175:210-218. [PMID: 35130050 DOI: 10.7326/m21-2793] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Treatment of cervical intraepithelial neoplasia grade 3 (CIN 3) removes or destroys part of the cervix and might subsequently influence pregnancy outcomes. OBJECTIVE To investigate pregnancy outcomes in women diagnosed with CIN 3. DESIGN Population- and sibling-matched cohort study. SETTING Sweden, 1973 to 2018. PARTICIPANTS The general population comparison included 78 450 singletons born to women diagnosed with CIN 3 and 784 500 matched singletons born to women in the general population who had no CIN 3 diagnosis; the sibling comparison included 23 199 singletons born to women diagnosed with CIN 3 and 28 135 singletons born to their sisters without a CIN 3 diagnosis. MEASUREMENTS Preterm birth, including spontaneous or iatrogenic preterm birth; infection-related outcomes, including chorioamnionitis and infant sepsis; and early neonatal death, defined as death during the first week after birth. RESULTS Compared with the matched general population, women previously diagnosed with CIN 3 were more likely to have a preterm birth, especially extremely preterm (22 to 28 weeks; odds ratio [OR], 3.00 [95% CI, 2.69 to 3.34]) or spontaneous preterm (OR, 2.12 [CI, 2.05 to 2.20]); infection-related outcomes, including chorioamnionitis (OR, 3.23 [CI, 2.89 to 3.62]) and infant sepsis (OR, 1.72 [CI, 1.60 to 1.86]); or early neonatal death (OR, 1.83 [CI, 1.61 to 2.09]). Sibling comparison analyses rendered largely similar results. Over time, the risk difference attenuated for all outcomes and disappeared for early neonatal death. LIMITATION Lack of data on CIN 3 treatment and spontaneous abortion. CONCLUSION History of CIN 3 is associated with adverse pregnancy outcomes even after accounting for familial factors. Decreasing risk estimates over time suggest that adverse pregnancy outcomes among women diagnosed with CIN 3 may be minimized by improving treatment methods. PRIMARY FUNDING SOURCE The Swedish Research Council, the Swedish Cancer Society, and the Swedish Research Council for Health, Working Life and Welfare.
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Affiliation(s)
- Wei He
- Chronic Disease Research Institute, The Children's Hospital, and National Clinical Research Center for Child Health, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China, Department of Nutrition and Food Hygiene, School of Public Health, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China, and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (W.H.)
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (P.S., K.C.)
| | - Fang Fang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden (F.F.)
| | - Verena Sengpiel
- Region Västra Götaland, Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg and Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (V.S.)
| | - Björn Strander
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, and Regional Cancer Center West, Gothenburg, Sweden (B.S.)
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (P.S., K.C.)
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Niu J, Cheng M, Hong Z, Ling J, Di W, Gu L, Qiu L. The effect of 5-Aminolaevulinic Acid Photodynamic Therapy versus CO 2 laser in the Treatment of Cervical Low-grade Squamous Intraepithelial Lesions with High-Risk HPV Infection: A non-randomized, controlled pilot study. Photodiagnosis Photodyn Ther 2021; 36:102548. [PMID: 34562648 DOI: 10.1016/j.pdpdt.2021.102548] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/01/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are insufficient studies comparing the efficacy of 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) against CO2 laser therapy in the treatment of cervical low-grade squamous intraepithelial lesion (LSIL) with high-risk human papillomavirus (HR-HPV), especially for long-term efficacy. METHODS Patients with cervical LSIL and HR-HPV infection were divided into two treatment groups based on their own choice. All patients had a follow-up test including HPV testing, cytology and colposcopy at 4-6 months and 12 months after the treatment. RESULTS (1) Among 277 patients, 176 patients received 5-ALA PDT and 101 patients received CO2 laser therapy. (2) 4-6 months after treatment, there was no significant difference between two groups in the complete remission (CR) rates of cervical LSIL and the clearance rate of HR-HPV infection. (3) 12 months after treatment, compared with the CO2 laser group, the CR rates of cervical LSIL in the 5-ALA PDT group was significantly higher than the CO2 laser group. There was no statistical difference in the clearance rate of HR-HPV infection between the two groups. (4) 12 months after treatment, the recurrence rate of cervical lesions and the reinfection rate of HR-HPV infection in 5-ALA PDT group were significantly lower than those in CO2 laser group. CONCLUSION The effect of 5-ALA PDT is similar to CO2 laser at 4-6 months. The long-term efficacy of 5-ALA PDT appears better than CO2 laser. As a non-invasive treatment, 5-ALA PDT is a highly effective therapeutic procedure for cervical LSIL with HR-HPV infection.
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Affiliation(s)
- Jiaxin Niu
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine
| | - Mengxing Cheng
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine
| | - Zubei Hong
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine
| | - Jiayan Ling
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine
| | - Wen Di
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine; State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine
| | - Liying Gu
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine.
| | - Lihua Qiu
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiaotong University School of Medicine; Shanghai Key Laboratory of Gynecologic Oncology, Renji Hospital, Shanghai Jiaotong University School of Medicine; State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine.
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Sachan R, Shukla A, Patel M, Sachan P, Verma M, Singh U. Single step “See and Treat” strategy might be replacing the “conventional three step strategy” in management of preinvasive cervical lesions at tertiary center: A North Indian study. J Cancer Res Ther 2021; 18:1541-1547. [DOI: 10.4103/jcrt.jcrt_799_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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7
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Zhao XL, Xu XQ, Duan XZ, Rezhake R, Hu SY, Wang Y, Xia CF, Zhang X, Qiao YL, Sankaranarayanan R, Zhao FH, Basu P. Comparative performance evaluation of different HPV tests and triaging strategies using self-samples and feasibility assessment of thermal ablation in 'colposcopy and treat' approach: A population-based study in rural China. Int J Cancer 2020; 147:1275-1285. [PMID: 31970767 DOI: 10.1002/ijc.32881] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/15/2019] [Accepted: 01/08/2020] [Indexed: 01/07/2023]
Abstract
Human papillomavirus (HPV) test, self-sampling and thermal ablation for cervical intraepithelial neoplasia (CIN) have been developed separately to increase screening coverage and treatment compliance of cervical cancer screening programmes. A large-scale study in rural China screened 9,526 women with their combinations to explore the optimal cervical cancer-screening cascade in the real-world. Participants received careHPV and polymerase chain reaction (PCR) HPV tests on self-collected samples. Women positive on either HPV test underwent colposcopy, biopsy and thermal ablation in a single visit. Samples positive on either HPV test were retested for genotyping. Absolute and relative performance of HPV tests, triage strategies, 'colposcopy and thermal ablation' approach were statistically evaluated. PCR HPV test detected 33.3% more CIN grade two or worse (CIN2+) at a cost of 28.1% more colposcopies compared to careHPV. Sensitivities of PCR HPV and careHPV tests to detect CIN2+ were 96.7 and 72.5%. Specificities for the same disease outcome were 82.1 and 86.0%. Triaging HPV-positive women with HPV16/18 genotyping considerably improved the positive predictive value for CIN2+ (4.8-5.0 to 18.2-19.2%). Ninety-six women positive on HPV and having abnormal colposcopy were eligible for thermal ablation and all accepted same-day treatment, contributing to 64.6% being treated appropriately (CIN1+ on histopathology), which reached up to 84.8% among women positive on HPV 16/18 triage. No serious side-effects/complications were reported. The combination of PCR HPV test followed by HPV 16/18 triaging on self-collected samples and colposcopy of triage positive women followed by immediate thermal ablation might be the appropriate screening cascade for rural China.
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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
| | - Xiao-Qian Xu
- 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
| | - Xian-Zhi Duan
- Department of Obstetrics and Gynecology, Beijing Tongren Hospital, Beijing, China
| | - Remila Rezhake
- 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
| | - Yan Wang
- 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
| | - Chang-Fa Xia
- 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
| | - Xun Zhang
- Department of Pathology, 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
- RTI (Research Triangle Institute) International, New Delhi, India
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - 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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Aitken CA, Siebers AG, Matthijsse SM, Jansen EEL, Bekkers RLM, Becker JH, Ter Harmsel B, Roovers JPWR, van Kemenade FJ, de Kok IMCM. Management and treatment of cervical intraepithelial neoplasia in the Netherlands after referral for colposcopy. Acta Obstet Gynecol Scand 2019; 98:737-746. [PMID: 30687935 PMCID: PMC6593855 DOI: 10.1111/aogs.13547] [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] [Received: 08/01/2018] [Revised: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 01/09/2023]
Abstract
Introduction The aim of this study was to describe trends in the diagnosis and treatment of women referred from the national screening program with cervical intraepithelial neoplasia (CIN) in the Netherlands, and to compare these trends with national guidelines and identify potential areas for improvement for the new primary high‐risk HPV screening program. Material and methods We conducted a population‐based cohort study using data from the Dutch pathology archive. Women aged 29‐63 years who took part in the Dutch cervical screening program between 1 January 2005 and 31 December 2014 were selected. Three referral groups were identified: direct referrals and those referred after either one (first indirect referrals) or two (second indirect referrals) repeat cytology tests, totaling 85 239 referrals for colposcopy. The most invasive management technique and the most severe diagnosis of each screening episode was identified. Rates of management techniques were calculated separately by referral type, highest CIN diagnosis and age group. Results In all, 85.1% of CIN 3 lesions were treated with excision (either large excision or hysterectomy) and 26.4% of CIN 1 lesions were treated with large excision. Rates of overtreatment (CIN 1 or less) in see‐and‐treat management were higher for indirect referrals than for direct referrals and increased with age. Large excision rates increased with CIN diagnosis severity. Conclusions Despite guideline recommendations not to treat, CIN 1 lesions were treated in just over 25% of cases and approximately 15% of CIN 3 lesions were possibly undertreated. Given the expected increase in CIN detection in the new primary high‐risk HPV screening program, reduction in CIN 1 treatment and CIN 2 treatment in younger women is needed to avoid an increase in potential harm.
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Affiliation(s)
- Clare A Aitken
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Albert G Siebers
- PALGA, the nationwide network and registry of histo- and cytopathology in the Netherlands, Houton, the Netherlands.,Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Suzette M Matthijsse
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.,BresMed Health Solutions, Utrecht, the Netherlands
| | - Erik E L Jansen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ruud L M Bekkers
- Department of Gynecology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands.,Department of Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen H Becker
- Department of Obstetrics and Gynecology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Bram Ter Harmsel
- Department of Gynecology, Roosevelt Kliniek, Leiden, the Netherlands
| | - Jan-Paul W R Roovers
- Bergman Clinics (Gynecology), Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Inge M C M de Kok
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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Nghiem VT, Davies KR, Beck JR, Follen M, Cantor SB. Overtreatment and Cost-Effectiveness of the See-and-Treat Strategy for Managing Cervical Precancer. Cancer Epidemiol Biomarkers Prev 2016; 25:807-14. [PMID: 26929242 DOI: 10.1158/1055-9965.epi-15-1044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND See-and-treat using loop electrosurgical excision procedure (LEEP) has been recommended as an alternative in managing high-grade cervical squamous intraepithelial lesions, but existing literature lacks evidence of the strategy's cost-effectiveness. We evaluated the overtreatment and cost-effectiveness of the see-and-treat strategy compared with usual care. METHODS We modeled a hypothetical cohort of 40-year-old females who had not been screened for cervical cancer and followed them through their lifetimes using a Markov model. From a U.S. health-system perspective, the analysis was conducted in 2012 dollars and measured effectiveness in quality-adjusted life-years (QALY). We estimated incremental cost-effectiveness ratios (ICER) using a willingness-to-pay threshold of $50,000/QALY. The robustness of the see-and-treat strategy's cost-effectiveness and its overtreatment rates were further examined in various sensitivity analyses. RESULTS In the base-case, the see-and-treat strategy yielded an ICER of $70,774/QALY compared with usual care. For most scenarios in the deterministic sensitivity analysis, this strategy had ICERs larger than $50,000/QALY, and its cost-effectiveness was sensitive to the disutility of LEEP treatment and biopsy-directed treatment adherence under usual care. Probabilistic sensitivity analysis showed that the see-and-treat strategy had a 50.1% chance to be cost-effective. It had an average overtreatment rate of 7.1% and a 78.8% chance to have its overtreatment rate lower than the 10% threshold. CONCLUSION The see-and-treat strategy induced an acceptable overtreatment rate. Its cost-effectiveness, compared with usual care, was indiscriminating at the chosen willingness-to-pay threshold but much improved when the threshold increased. IMPACT The see-and-treat strategy was reasonable for particular settings, that is, those with low treatment adherence. Cancer Epidemiol Biomarkers Prev; 25(5); 807-14. ©2016 AACR.
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Affiliation(s)
- Van T Nghiem
- Center for Health Promotion and Prevention Research, The University of Texas School of Public Health, Houston, Texas. Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kalatu R Davies
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Robert Beck
- Cancer Prevention and Control Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Michele Follen
- Department of Obstetrics & Gynecology, Brookdale University Hospital & Medical Center, Brooklyn, New York
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Sharp L, Cotton S, Cruickshank M, Gray N, Smart L, Whynes D, Little J. Impact of post-colposcopy management on women's long-term worries: results from the UK population-based TOMBOLA trial. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2015; 42:43-51. [DOI: 10.1136/jfprhc-2015-101170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 08/12/2015] [Indexed: 11/04/2022]
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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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Kisser A, Zechmeister-Koss I. A systematic review of p16/Ki-67 immuno-testing for triage of low grade cervical cytology. BJOG 2014; 122:64-70. [DOI: 10.1111/1471-0528.13076] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2014] [Indexed: 12/14/2022]
Affiliation(s)
- A Kisser
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna Austria
| | - I Zechmeister-Koss
- Ludwig Boltzmann Institute for Health Technology Assessment; Vienna Austria
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13
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Ezechi OC, Petterson KO, Gbajabiamila TA, Idigbe IE, Kuyoro O, Ujah IAO, Ostergren PO. Predictors of default from follow-up care in a cervical cancer screening program using direct visual inspection in south-western Nigeria. BMC Health Serv Res 2014; 14:143. [PMID: 24678898 PMCID: PMC3986612 DOI: 10.1186/1472-6963-14-143] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 03/27/2014] [Indexed: 11/24/2022] Open
Abstract
Background Increasingly evidence is emerging from south East Asia, southern and east Africa on the burden of default to follow up care after a positive cervical cancer screening/diagnosis, which impacts negatively on cervical cancer prevention and control. Unfortunately little or no information exists on the subject in the West Africa sub region. This study was designed to determine the proportion of and predictors and reasons for default from follow up care after positive cervical cancer screen. Method Women who screen positive at community cervical cancer screening using direct visual inspection were followed up to determine the proportion of default and associated factors. Multivariate logistic regression was used to determine independent predictors of default. Results One hundred and eight (16.1%) women who screened positive to direct visual inspection out of 673 were enrolled into the study. Fifty one (47.2%) out of the 108 women that screened positive defaulted from follow-up appointment. Women who were poorly educated (OR: 3.1, CI: 2.0 – 5.2), or lived more than 10 km from the clinic (OR: 2.0, CI: 1.0 – 4.1), or never screened for cervical cancer before (OR: 3.5, CI:3:1–8.4) were more likely to default from follow-up after screening positive for precancerous lesion of cervix . The main reasons for default were cost of transportation (48.6%) and time constraints (25.7%). Conclusion The rate of default was high (47.2%) as a result of unaffordable transportation cost and limited time to keep the scheduled appointment. A change from the present strategy that involves multiple visits to a “see and treat” strategy in which both testing and treatment are performed at a single visit is recommended.
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Tan J, Delaney P, McLaren WJ. Confocal endomicroscopy: a novel maging technique forin vivohistology of cervical intraepithelial neoplasia. Expert Rev Med Devices 2014; 4:863-71. [DOI: 10.1586/17434440.4.6.863] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Vercellino GF, Erdemoglu E, Chiantera V, Malak AH, Vasiljeva K, Drechsler I, Dückelmann AM, Richter J, Schneider A, Böhmer G. A multicentric randomized study comparing two techniques of magnification assisted loop excision of high-grade cervical intraepithelial neoplasia: video exoscopy and colposcopy. Arch Gynecol Obstet 2013; 289:1301-7. [DOI: 10.1007/s00404-013-3134-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/12/2013] [Indexed: 11/24/2022]
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Ratnavelu N, Biliatis I, Cross PA, Naik R. Ten-year outcomes of a one-stop colposcopy clinic: a unique service for low grade cytology. Eur J Obstet Gynecol Reprod Biol 2013; 169:287-91. [PMID: 23510950 DOI: 10.1016/j.ejogrb.2013.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Revised: 01/28/2013] [Accepted: 02/16/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine patient acceptance of treatment, and treatment default rate, at a one-stop clinic, and to establish the concordance of punch and loop histology for high grade cervical intraepithelial neoplasia (CIN) by date of excisional treatment. STUDY DESIGN Retrospective review of computerised data and clinic files of 2090 women with low grade cytology undergoing cervical punch biopsies between 2001 and 2011 at the colposcopy clinic, Northern Gynaecological Oncology Centre, Gateshead, UK. Punch biopsies were micro-wave processed and reported within 2h, and women were offered immediate loop biopsy if high grade CIN was confirmed. Data were collected regarding patients' choice for immediate or deferred treatment and default rate. Histological outcomes were compared between those undergoing immediate and deferred loop biopsies. RESULTS Of the 360 women (17%) with high grade CIN on punch biopsy, 259 (72%) opted to have immediate loop treatment at the first visit. Of these women, 190 (73%) had high grade CIN on loop histology. Of 97 women (27%) who had deferred loop biopsy after a median of 28 days (range 7-112), 65 (67%) had high grade CIN on loop histology. The default rate at return for treatment appointments was 0% amongst all patients. CONCLUSION This one-stop colposcopy clinic reduces defaulting from treatment. It has proven to be a sustainable service and the majority of women, when given the choice, opt for immediate loop treatment at their first visit.
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Affiliation(s)
- Nithya Ratnavelu
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, United Kingdom.
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18
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Shinn E, Qazi U, Gera S, Brodovsky J, Simpson J, Follen M, Basen-Engquist K, Macaulay C. Physician attitudes toward dissemination of optical spectroscopy devices for cervical cancer control: an industrial-academic collaborative study. ACTA ACUST UNITED AC 2012; 9:S67-77; quiz 77.e1-6. [PMID: 22340642 DOI: 10.1016/j.genm.2011.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 11/08/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optical spectroscopy has been studied for biologic plausibility, technical efficacy, clinical effectiveness, patient satisfaction, and cost-effectiveness. OBJECTIVE We sought to identify health care provider attitudes or practices that might act as barriers or to the dissemination of this new technology. METHODS Through an academic-industrial partnership, we conducted a series of focus groups to examine physician barriers to optical diagnosis. The study was conducted in 2 stages. First, a pilot group of 10 physicians (8 obstetrician gynecologists and 2 family practitioners) was randomly selected from 8 regions of the United States and each physician was interviewed individually. Physicians were presented with the results of a large trial (N = 980) testing the accuracy of a spectroscopy-based device in the detection of cervical neoplasia. They were also shown a prototype of the device and were given a period of time to ask questions and receive answers regarding the device. They were also asked to provide feedback on a questionnaire that was then revised and presented to 3 larger focus groups (n = 13, 15, and 17 for a total N = 45). The larger focus groups were conducted during national scientific meetings with 20 obstetrician gynecologists and 25 primary care physicians (family practitioners and internists). RESULTS When asked about the dissemination potential of the new cervical screening technology, all study groups tended to rely on established clinical guidelines from their respective professional societies with regard to the screening and diagnosis of cervical cancer. In addition, study participants consistently agreed that real-time spectroscopy would be viewed positively by their patients. Participants were positive about the new technology's potential as an adjunct to colposcopy and agreed that the improved accuracy would result in reduced health care costs (due to decreased biopsies and decreased visits). Although all participants saw the potential of real-time diagnosis, there were many perceived barriers. These barriers included changes in scheduling and work-flow, liability, documentation, ease of use, length of training, device cost, and reimbursement by third-party payers. CONCLUSIONS Barriers exist to the dissemination of optical technologies into physician practice. These will need to be addressed before cervical screening and diagnosis programs can take advantage of spectroscopy-based instruments for cancer control.
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Affiliation(s)
- Eileen Shinn
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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Yamal JM, Zewdie GA, Cox DD, Atkinson EN, Cantor SB, MacAulay C, Davies K, Adewole I, Buys TPH, Follen M. Accuracy of optical spectroscopy for the detection of cervical intraepithelial neoplasia without colposcopic tissue information; a step toward automation for low resource settings. JOURNAL OF BIOMEDICAL OPTICS 2012; 17:047002. [PMID: 22559693 PMCID: PMC3380950 DOI: 10.1117/1.jbo.17.4.047002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 01/30/2012] [Accepted: 02/17/2012] [Indexed: 05/24/2023]
Abstract
Optical spectroscopy has been proposed as an accurate and low-cost alternative for detection of cervical intraepithelial neoplasia. We previously published an algorithm using optical spectroscopy as an adjunct to colposcopy and found good accuracy (sensitivity=1.00 [95% confidence interval (CI)=0.92 to 1.00], specificity=0.71 [95% CI=0.62 to 0.79]). Those results used measurements taken by expert colposcopists as well as the colposcopy diagnosis. In this study, we trained and tested an algorithm for the detection of cervical intraepithelial neoplasia (i.e., identifying those patients who had histology reading CIN 2 or worse) that did not include the colposcopic diagnosis. Furthermore, we explored the interaction between spectroscopy and colposcopy, examining the importance of probe placement expertise. The colposcopic diagnosis-independent spectroscopy algorithm had a sensitivity of 0.98 (95% CI=0.89 to 1.00) and a specificity of 0.62 (95% CI=0.52 to 0.71). The difference in the partial area under the ROC curves between spectroscopy with and without the colposcopic diagnosis was statistically significant at the patient level (p=0.05) but not the site level (p=0.13). The results suggest that the device has high accuracy over a wide range of provider accuracy and hence could plausibly be implemented by providers with limited training.
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Affiliation(s)
- Jose-Miguel Yamal
- The University of Texas Health Science Center at Houston, Division of Biostatistics, School of Public Health, 1200 Herman Pressler, RAS W928, Houston, Texas 77030, USA.
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Yang HP, Zuna RE, Schiffman M, Walker JL, Sherman ME, Landrum LM, Moxley K, Gold MA, Dunn ST, Allen RA, Zhang R, Long R, Wang SS, Wentzensen N. Clinical and pathological heterogeneity of cervical intraepithelial neoplasia grade 3. PLoS One 2012; 7:e29051. [PMID: 22253702 PMCID: PMC3258246 DOI: 10.1371/journal.pone.0029051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 11/18/2011] [Indexed: 11/18/2022] Open
Abstract
Objective Cervical intraepithelial neoplasia grade 3 (CIN3), the immediate cervical cancer precursor, is a target of cervical cancer prevention. However, less than half of CIN3s will progress to cancer. Routine treatment of all CIN3s and the majority of CIN2s may lead to overtreatment of many lesions that would not progress. To improve our understanding of CIN3 natural history, we performed a detailed characterization of CIN3 heterogeneity in a large referral population in the US. Methods We examined 309 CIN3 cases in the SUCCEED, a large population-based study of women with abnormal cervical cancer screening results. Histology information for 12 individual loop electrosurgical excision procedure (LEEP) segments was evaluated for each woman. We performed case-case comparisons of CIN3s to analyze determinants of heterogeneity and screening test performance. Results CIN3 cases varied substantially by size (1–10 LEEP segments) and by presentation with concomitant CIN2 and CIN1. All grades of CINs were equally distributed over the cervical surface. In half of the women, CIN3 lesions were found as multiple distinct lesions on the cervix. Women with large and solitary CIN3 lesions were more likely to be older, have longer sexual activity span, and have fewer multiple high risk HPV infections. Screening frequency, but not HPV16 positivity, was an important predictor of CIN3 size. Large CIN3 lesions were also characterized by high-grade clinical test results. Conclusions We demonstrate substantial heterogeneity in clinical and pathological presentation of CIN3 in a US population. Time since sexual debut and participation in screening were predictors of CIN3 size. We did not observe a preferential site of CIN3 on the cervical surface that could serve as a target for cervical biopsy. Cervical cancer screening procedures were more likely to detect larger CIN3s, suggesting that CIN3s detected by multiple independent diagnostic tests may represent cases with increased risk of invasion.
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Affiliation(s)
- Hannah P Yang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, United States of America.
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Buys TPH, Cantor SB, Guillaud M, Adler-Storthz K, Cox DD, Okolo C, Arulogon O, Oladepo O, Basen-Engquist K, Shinn E, Yamal JM, Beck JR, Scheurer ME, van Niekerk D, Malpica A, Matisic J, Staerkel G, Atkinson EN, Bidaut L, Lane P, Benedet JL, Miller D, Ehlen T, Price R, Adewole IF, MacAulay C, Follen M. Optical technologies and molecular imaging for cervical neoplasia: a program project update. ACTA ACUST UNITED AC 2011; 9:S7-24. [PMID: 21944317 DOI: 10.1016/j.genm.2011.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 08/02/2011] [Indexed: 12/23/2022]
Abstract
There is an urgent global need for effective and affordable approaches to cervical cancer screening and diagnosis. In developing nations, cervical malignancies remain the leading cause of cancer-related deaths in women. This reality may be difficult to accept given that these deaths are largely preventable; where cervical screening programs have been implemented, cervical cancer-related deaths have decreased dramatically. In developed countries, the challenges of cervical disease stem from high costs and overtreatment. The National Cancer Institute-funded Program Project is evaluating the applicability of optical technologies in cervical cancer. The mandate of the project is to create tools for disease detection and diagnosis that are inexpensive, require minimal expertise, are more accurate than existing modalities, and can be feasibly implemented in a variety of clinical settings. This article presents the status and long-term goals of the project.
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Affiliation(s)
- Timon P H Buys
- Imaging Unit, Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada.
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Reply. Am J Obstet Gynecol 2011. [DOI: 10.1016/j.ajog.2011.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ulrich D, Tamussino K, Reich O. Should patients with cytologic high-grade intraepithelial lesions of the cervix be treated without colposcopic-guided biopsy? Am J Obstet Gynecol 2011; 205:e8-9; author reply e9. [PMID: 21600551 DOI: 10.1016/j.ajog.2011.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
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Long-term psychosocial impact of alternative management policies in women with low-grade abnormal cervical cytology referred for colposcopy: a randomised controlled trial. Br J Cancer 2010; 104:255-64. [PMID: 21179033 PMCID: PMC3031895 DOI: 10.1038/sj.bjc.6606042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The debate continues regarding the best management for women with low-grade abnormal cervical cytology attending colposcopy. We compared psychosocial outcomes of alternative management policies in these women. METHODS In all, 989 women, aged 20-59 years, with low-grade abnormal cytology, were randomised to immediate large loop excision (LLETZ) or two to four targeted punch biopsies taken immediately with recall for LLETZ if these showed cervical intra-epithelial neoplasia 2/3. At 6 weeks after the last procedure, women completed the hospital anxiety and depression scale (HADS) and the impact of event scale (IES). At 12, 18, 24 and 30 months post recruitment, women completed the HADS and process outcome specific measure (POSM). Prevalence of significant depression (≥ 8), significant anxiety (≥ 11) and distress (≥ 9) and median POSM scores were compared between arms. Multivariate odds ratios (ORs) for immediate LLETZ vs biopsy and recall were computed. RESULTS Over the entire follow-up, there was no significant difference between arms in cumulative prevalence or risk of significant depression (OR=0.78, 95% CI 0.52-1.17) or significant anxiety (OR=0.83, 95% CI 0.57-1.19). At 6 weeks post procedure, distress did not differ significantly between arms. At later time points, 8-11% had significant depression and 14-16% had significant anxiety but with no differences between arms. The POSM scores did not differ between the arms. CONCLUSIONS There is no difference in long- or short-term psychosocial outcomes of immediate LLETZ and punch biopsies with selective recall.
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Silfverdal L, Kemetli L, Sparén P, Andrae B, Strander B, Ryd W, Dillner J, Törnberg S. Risk of invasive cervical cancer in relation to clinical investigation and treatment after abnormal cytology: A population-based case-control study. Int J Cancer 2010; 129:1450-8. [DOI: 10.1002/ijc.25749] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 09/24/2010] [Accepted: 10/04/2010] [Indexed: 11/10/2022]
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Mutyaba T, Mirembe F, Sandin S, Weiderpass E. Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda. Reprod Health 2010; 7:4. [PMID: 20459733 PMCID: PMC2882355 DOI: 10.1186/1742-4755-7-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 05/10/2010] [Indexed: 12/31/2022] Open
Abstract
Background There is scant information on whether Human Immunodeficiency Virus (HIV) seropositivity has an influence on the outcome of treatment of precancerous cervical lesions using cryotherapy. We studied the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to HIV serostatus and described the outcomes of cryotherapy treatment. Methods Trained nurses examined women not previously screened for cervical cancer using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) in two family planning/post natal clinics in Kampala, Uganda, from February 2007 to August 2008. Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with precancerous cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy. Results Of the 5 105 women screened, 834 presented a positive screening test and were referred for colposcopy. Of these 625 (75%) returned for the colposcopic evaluation and were tested for HIV. For the 608 (97.5%) women in the age range 20-60 years, colposcopy revealed 169 women with cervical lesions: 128 had inflammation, 19 had low grade squamous intraepithelial lesion (LGSIL), 13 had high grade squamous intraepithelial lesion (HGSIL), 9 had invasive cervical cancer and 2 had inconclusive findings. Detection rates per 1 000 women screened were higher among the older women (41-60 years) compared to women aged 20-40 years. They were accordingly 55% and 20% for inflammation, 10% and 2% for LGSIL, 5% and 2% for HGSIL, 6% and 1% for invasive cervical cancer. Of the 608 women, 103 (16%) were HIV positive. HIV positivity was associated with higher likelihood of inflammation (RR = 1.7; 95% CI: 1.2-2.4). Conclusions Detection rates were higher among older women 41-60 years. Visual inspection of the cervix uteri with acetic acid (VIA) and Lugol's iodine (VILI) used as a sole method for cervical cancer screening would entail significant false positive results. HIV seropositivity was associated with a higher prevalence of inflammatory cervical lesions. In view of the small numbers and the relatively short follow up time of 3 months, we could not make an emphatic conclusion about the effect of HIV serostatus on cryotherapy treatment outcome.
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Affiliation(s)
- Twaha Mutyaba
- Department of Obstetrics and Gynecology, Makerere University, Medical School, P,O, Box 7072, Kampala, Uganda.
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Cytological surveillance compared with immediate referral for colposcopy in management of women with low grade cervical abnormalities: multicentre randomised controlled trial. BMJ 2009; 339:b2546. [PMID: 19638646 PMCID: PMC2718083 DOI: 10.1136/bmj.b2546] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the effectiveness of cytological surveillance in primary care compared with immediate referral for colposcopic examination in women with low grade abnormal results on cervical cytology tests. DESIGN Multicentre individually randomised controlled trial. SETTING NHS cervical screening programmes in Grampian, Tayside, and Nottingham. PARTICIPANTS 4439 women, aged 20-59, with a cytology result showing borderline nuclear abnormalities or mild dyskaryosis, October 1999-October 2002. INTERVENTIONS Cytological screening every six months in primary care (n=2223) or referral for colposcopy and related interventions (n=2216). All women were followed for three years, concluding with an exit appointment at which colposcopic examination was undertaken. Colposcopists assessing outcome at this appointment were blinded to randomisation. MAIN OUTCOME MEASURES Primary end point: cumulative incidence of cervical intraepithelial neoplasia grade II or more severe disease. Other end points: cervical intraepithelial neoplasia grade III or worse, clinically significant anxiety and depression, other self reported after effects, and rates of non-attendance. Analysis was by intention to treat; all those randomised were included. RESULTS The cumulative incidence of cervical intraepithelial neoplasia grade II or worse was 79 per 1000 person years in the colposcopy arm and 58 per 1000 person years in the cytological surveillance arm (relative risk 1.37, 95% confidence interval 1.19 to 1.57). This difference was less marked for cervical intraepithelial neoplasia grade III or more severe disease, but the incidence was still higher in the colposcopy arm (relative risk 1.26, 1.04 to 1.53). Among women randomised to immediate colposcopy, 79% (74.9% to 82.5%) of cases of cervical intraepithelial neoplasia grade II or worse were diagnosed at the time of the immediate colposcopy, while among women randomised to cytological surveillance, 77% (72.1% to 81.2%) of cases were detected by surveillance cytology and related interventions. Similar proportions of women were anxious or depressed in the two arms. A higher proportion of women in the colposcopy arm reported after effects, and these were of longer duration and more severe. Non-attendance was low in both arms. CONCLUSION The more marked difference between the arms in the occurrence of cervical intraepithelial neoplasia grade II or worse than in the occurrence of grade III or worse can probably be accounted for by the spontaneous regression of some cases of grade II neoplasia. Compared with cytological surveillance, a policy of immediate colposcopy detects more cervical intraepithelial neoplasia grade II or worse, and some more grade III or worse, but might lead to overtreatment. Such a policy is associated with a higher rate of reported after effects, which are more severe and of longer duration than those associated with cytological surveillance. TRIAL REGISTRATION ISRCTN 34841617.
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Biopsy and selective recall compared with immediate large loop excision in management of women with low grade abnormal cervical cytology referred for colposcopy: multicentre randomised controlled trial. BMJ 2009; 339:b2548. [PMID: 19638647 PMCID: PMC2718084 DOI: 10.1136/bmj.b2548] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2009] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare the effectiveness of punch biopsy and selective recall for treatment versus a policy of immediate treatment by large loop excision in the management of women with low grade abnormal cervical cytology referred for colposcopy. DESIGN Multicentre individually randomised controlled trial, nested within the NHS cervical screening programmes. SETTING Grampian, Tayside, and Nottingham. PARTICIPANTS 1983 women, aged 20-59, with cytology showing borderline nuclear abnormalities or mild dyskaryosis, October 1999-October 2002. INTERVENTIONS Immediate large loop excision or up to four targeted punch biopsies taken immediately with recall for treatment (by large loop excision) if these showed cervical intraepithelial neoplasia grade II or III or worse. Participants were followed for three years, concluding with an exit colposcopy. MAIN OUTCOME MEASURES Clinical end points: cumulative incidence of cervical intraepithelial neoplasia grade II or worse and grade III or worse at three years. Clinically significant anxiety and depression and self reported after effects assessed six weeks after colposcopy, biopsies, or large loop excision. RESULTS 879 women (44%) had a normal transformation zone at colposcopy and had no further procedures at that time. Colposcopists were less likely to classify the transformation zone as abnormal when the allocation was large loop excision (603 (60%) in the biopsy and selective recall group; 501 (51%) in the immediate large loop excision group). Of women randomised to biopsy and recall, 157 (16%) required a second clinic visit for treatment. Specimens from almost 60% (n=296) of women who underwent immediate large loop excision showed no cervical intraepithelial neoplasia (31%; n=156) or showed cervical intraepithelial neoplasia grade I (28%; n=140). The percentages of women diagnosed with grade II or worse up to and including the exit examination were 22% (n=216) in the biopsy and recall arm and 23% (n=228) in the immediate large loop excision arm. There was no significant difference between the arms in cumulative incidence of cervical intraepithelial neoplasia grade II or worse (adjusted relative for risk large loop excision v biopsy 1.04, 95% confidence interval 0.86 to 1.25) or grade III or worse (1.03, 0.79 to 1.34). A greater proportion of disease was detected at initial investigation and less during follow-up and at exit in the immediate large loop excision arm, but time of detection did not differ significantly between arms. Levels of anxiety and depression and reported pain did not differ between arms. Higher proportions of women randomised to large loop excision reported moderate or more severe bleeding and discharge. CONCLUSION A policy of targeted punch biopsies with subsequent treatment for cervical intraepithelial neoplasia grade II or III and cytological surveillance for grade I or less provides the best balance between benefits and harms for the management of women with low grade abnormal cytology referred for colposcopy. Immediate large loop excision results in overtreatment and more after effects and should not be recommended. TRIAL REGISTRATION ISRCTN 34841617.
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Abstract
OBJECTIVE To estimate the cost effectiveness of alternative methods of managing low grade cervical cytological abnormalities detected at routine screening. Design Cost analysis within multicentre individually randomised controlled trial. SETTING Grampian, Tayside, and Nottingham. PARTICIPANTS 4201 women with low grade abnormalities. INTERVENTIONS Cytological surveillance or referral to colposcopy for biopsy and recall if necessary or referral to colposcopy with immediate treatment based on colposcopic appearance. MAIN OUTCOME MEASURES Data on resource use collected from participants throughout the duration of the trial (36 months), enabling the estimation of both the direct (health care) and indirect (time and travel) costs of management. Quality of life assessed at recruitment and at 12, 18, 24, and 30 months, using the EQ-5D instrument. Economic outcomes expressed as costs per case of cervical intraepithelial neoplasia (grade II or worse) detected, by trial arm, as confirmed at exit, and cost utility ratios (cost per quality adjusted life year (QALY) gained) for the three pairwise comparisons of trial arms. RESULTS The mean three year discounted costs of surveillance, immediate treatment, and biopsy and recall were pound150.20 (euro177, $249), pound240.30 (euro283, $415), and pound241.10 (euro284, $4000), respectively, viewed from the health service perspective. From the social perspective, mean discounted costs were pound204.40 (euro241, $339), pound339.90 (euro440, $563), and pound327.50 (euro386, $543), respectively. Estimated at the means, the incremental cost effectiveness ratios indicated that immediate treatment was dominated by the other two management methods, although it did offer the lowest cost per case of cervical intraepithelial neoplasia detected and treated. The pronounced skews in the distributions indicated that probabilistic uncertainty analysis would offer more meaningful estimates of cost effectiveness. The observed differences in the cost effectiveness ratios between trial arms were not significant. CONCLUSION Judged within the time frame of the TOMBOLA evaluation, there is no compelling economic reason to favour any one follow-up method over either of the others. TRIAL REGISTRATION ISRCTN 34841617.
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Sharp L, Cotton S, Cochran C, Gray N, Little J, Neal K, Cruickshank M. After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial. BJOG 2009; 116:1506-14. [PMID: 19583712 DOI: 10.1111/j.1471-0528.2009.02263.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Few studies have investigated physical after-effects of colposcopy. We compared post-colposcopy self-reported pain, bleeding, discharge and menstrual changes in women who underwent: colposcopic examination only; cervical punch biopsies; and large loop excision of the transformation zone (LLETZ). DESIGN Observational study nested within a randomised controlled trial. SETTING Grampian, Tayside and Nottingham. POPULATION Nine hundred-and-twenty-nine women, aged 20-59, with low-grade cytology, who had completed their initial colposcopic management. METHODS Women completed questionnaires on after-effects at approximately 6-weeks, and on menstruation at 4-months, post-colposcopy. MAIN OUTCOME MEASURES Frequency of pain, bleeding, discharge; changes to first menstrual period post-colposcopy. RESULTS Seven hundred-and-fifty-one women (80%) completed the 6-week questionnaire. Of women who had only a colposcopic examination, 14-18% reported pain, bleeding or discharge. Around half of women who had biopsies only and two-thirds treated by LLETZ reported pain or discharge (biopsies: 53% pain, 46% discharge; LLETZ: 67% pain, 63% discharge). The frequency of bleeding was similar in the biopsy (79%) and LLETZ groups (87%). Women treated by LLETZ reported bleeding and discharge of significantly longer duration than other women. The duration of pain was similar across management groups. Forty-three percent of women managed by biopsies and 71% managed by LLETZ reported some change to their first period post-colposcopy, as did 29% who only had a colposcopic examination. CONCLUSIONS Cervical punch biopsies and, especially, LLETZ carry a substantial risk of after-effects. After-effects are also reported by women managed solely by colposcopic examination. Ensuring that women are fully informed about after-effects may help to alleviate anxiety and provide reassurance, thereby minimising the harms of screening.
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Three-step versus “see-and-treat” approach in women with high-grade squamous intraepithelial lesions in a low-resource country. Int J Gynaecol Obstet 2009; 106:202-5. [DOI: 10.1016/j.ijgo.2009.04.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Revised: 03/16/2009] [Accepted: 04/14/2009] [Indexed: 11/18/2022]
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HPV Determination in the Control After LEEP Due to CIN II-III: Prospective Study and Predictive Model. Int J Gynecol Pathol 2009; 28:120-6. [DOI: 10.1097/pgp.0b013e3181891459] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Adam Y, van Gelderen CJ, de Bruyn G, McIntyre JA, Turton DA, Martinson NA. Predictors of persistent cytologic abnormalities after treatment of cervical intraepithelial neoplasia in Soweto, South Africa: a cohort study in a HIV high prevalence population. BMC Cancer 2008; 8:211. [PMID: 18657270 PMCID: PMC2515323 DOI: 10.1186/1471-2407-8-211] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Accepted: 07/25/2008] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In the presence of both HIV infection and cervical intraepithelial neoplasia (CIN), the risk of cancer development despite treatment may be greater. We investigated clinical predictors of persistent cytological abnormalities in women who had had a large loop excision of the transformation zone (LLETZ). METHODS Women with high grade squamous intraepithelial lesions or worse (HSIL), less severe abnormalities which persisted and any abnormality in women who are HIV-infected, were referred to the colposcopy clinic. HIV infection was ascertained by self-report. A LLETZ was performed on all patients with HSIL or higher on Papanicolaou (Pap) smear or colposcopy, LSIL or higher in patients who are HIV-infected, where the colposcopy is inadequate, and when there was a discrepancy between colposcopy and cytology by one or more grades. Women with abnormal follow-up smears were compared to those with normal smears. We examined the association between abnormal follow-up smears and demographic and clinical predictors using logistic regression RESULTS The median time between LLETZ and first follow-up Pap smear was rather short at 122 days. Persistent cytological abnormalities occurred in 49% of our patients after LLETZ. Predictors of persistence included the presence of disease at both margins and HIV infection. Among the latter, disease at the excision margins and CD4+ cell count were important predictors. In these women, disease at the endocervical margin, both margins, and disease only at the ectocervical margin were associated with increased odds of persistent abnormalities on follow-up cervical smear. CONCLUSION We showed extremely high risk of cytological abnormality at follow-up after treatment more so in patients with incomplete excision and in the presence of immunocompromise. It remains uncertain whether recurrent CIN is a surrogate marker for invasive cervical cancer.
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Affiliation(s)
- Yasmin Adam
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.
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Ahmed AS, Goumalatsos G, Akbar N, Lawton FG, Savvas M. Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis. Cytopathology 2007; 19:94-105. [PMID: 17937774 DOI: 10.1111/j.1365-2303.2007.00478.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the 4-year outcome of patients after one smear showing mild dyskaryosis with respect to smear regression rate, prevalence of cervical intraepithelial neoplasia (CIN) and the effect of age. METHODS Retrospective analysis of patients diagnosed with initial mildly dyskaryotic smear during the year 2000 with a follow-up period of 48 months. These women had not had any previous abnormal smears. SETTINGS Cytopathology Department and Colposcopy Unit, King's College Hospital, London, UK. RESULTS We identified 524 patients of whom 375 patients with complete follow-up data are included. The age range was 19-67 years with a median of 29 years. There were 207 patients aged 35 years or less (55%). At 6 months, 258 smears were performed and 47.8% of them were negative (95% CI: 41.6-54.0%). The total number of negative follow-up smears in the first year was 198 out of a total of 397 smears performed (50%). This proportion has significantly increased between 1 and 4 years' follow-up to 67.5% (RR: 1.24; 95% CI: 1.14-1.35). Over the 4-year period, 791 smears were performed and 477 were negative (60.3%; 95% CI: 56.9-63.7%). Of the 477 negative smears there were only 61 smears (12.8%; 95% CI: 10-16%), in 54 patients (14%; 95% CI: 11-18%) that reverted back to low-grade cytological abnormality. In only one case the repeat smear showed high-grade abnormality after initial negative follow-up; however, on biopsy, histology showed CIN I. Out of the 375 patients, 70 required treatment with excisional biopsy (19%; 95% CI: 15.0-22.9%). Histology confirmed high-grade CIN in only 41 cases giving a prevalence of 11% (95% CI: 8.1-14.5%). There were no cases of microinvasive or invasive cancer detected. Age (< or =35 years versus >35 years) did not significantly affect either cytological or histological outcome. CONCLUSION Sixty per cent of follow-up smears after initial mild dyskaryosis subsequently became negative; of them 87.2% remained negative over the 4 year follow-up. Treatment was only required in 19% of patients, with 11% prevalence of high-grade CIN. Age did not affect the outcome. These results are reassuring and indicate that colposcopic referral may not be necessary after only one mildly dyskaryotic smear.
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Affiliation(s)
- A S Ahmed
- Gynaecology Dept, King's College Hospital, London, UK.
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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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Bentley E, Cotton SC, Cruickshank ME, Duncan I, Gray NM, Jenkins D, Little J, Neal K, Philips Z, Russell I, Seth R, Sharp L, Waugh N. Refining the Management of Low-Grade Cervical Abnormalities in the UK National Health Service and Defining the Potential for Human Papillomavirus Testing: A Commentary on Emerging Evidence. J Low Genit Tract Dis 2006; 10:26-38. [PMID: 16378029 DOI: 10.1097/01.lgt.0000192695.93172.75] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elaine Bentley
- University of Nottingham Medical School at Derby, Derby City General Hospital, UK
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