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Tinelli M, Athanasiou A, Veroniki AA, Efthimiou O, Kalliala I, Bowden S, Paraskevaidi M, Lyons D, Martin-Hirsch P, Bennett P, Paraskevaidis E, Salanti G, Kyrgiou M, Naci H. Treatment methods for cervical intraepithelial neoplasia in England: A cost-effectiveness analysis. BJOG 2024; 131:1411-1419. [PMID: 38659133 DOI: 10.1111/1471-0528.17829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To compare the cost-effectiveness of different treatments for cervical intraepithelial neoplasia (CIN). DESIGN A cost-effectiveness analysis based on data available in the literature and expert opinion. SETTING England. POPULATION Women treated for CIN. METHODS We developed a decision-analytic model to simulate the clinical course of 1000 women who received local treatment for CIN and were followed up for 10 years after treatment. In the model we considered surgical complications as well as oncological and reproductive outcomes over the 10-year period. The costs calculated were those incurred by the National Health Service (NHS) of England. MAIN OUTCOME MEASURES Cost per one CIN2+ recurrence averted (oncological outcome); cost per one preterm birth averted (reproductive outcome); overall cost per one adverse oncological or reproductive outcome averted. RESULTS For young women of reproductive age, large loop excision of the transformation zone (LLETZ) was the most cost-effective treatment overall at all willingness-to-pay thresholds. For postmenopausal women, LLETZ remained the most cost-effective treatment up to a threshold of £31,500, but laser conisation became the most cost-effective treatment above that threshold. CONCLUSIONS LLETZ is the most cost-effective treatment for both younger and older women. However, for older women, more radical excision with laser conisation could also be considered if the NHS is willing to spend more than £31,500 to avert one CIN2+ recurrence.
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Affiliation(s)
- Michela Tinelli
- Department of Health Policy, The London School of Economics and Political Science, London, UK
- Care Policy Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Antonios Athanasiou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
| | - Areti Angeliki Veroniki
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Ilkka Kalliala
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sarah Bowden
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Paraskevaidi
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
| | - Deirdre Lyons
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Phillip Bennett
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
| | - Evangelos Paraskevaidis
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
- Department of Obstetrics and Gynaecology, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Institute of Reproductive and Developmental Biology (IRDB), Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
| | - Huseyin Naci
- Department of Health Policy, The London School of Economics and Political Science, London, UK
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Liu Y, Medlege HB, Kang Y, Wu L, Yang W, Zhang Y, Tian Y. Clinical efficacy of a new therapeutic option for lower genital tract lesions: 5-ALA photodynamic therapy. Lasers Med Sci 2024; 39:172. [PMID: 38965092 DOI: 10.1007/s10103-024-04129-5] [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: 10/28/2023] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
The study utilized 5-ALA-PDT to treat patients with CIN or VaIN and assessed their clinical response, HPV clearance, and influencing factors after photodynamic therapy (PDT). This study involved 56 patients who received 5-ALA-PDT in a single center from May 2020 to March 2022, including 12 patients with CIN, 30 patients with VaIN, and 14 patients with both CIN and VaIN. Follow-up were conducted within 6 and 12 months after treatment to evaluate the clinical effectiveness of PDT. The assessment criteria included histological response (ER, elimination rate, RR, regression rate) and HPV clearance. Additionally, factors that could potentially influence the outcomes were analyzed. After PDT, the histological response showed an ER of 48.2% (27/56) and a RR of 80.4% (45/56) within 6 months of follow-up. The elimination rate increased to 69.6% (39/56) within 12 months, along with a regression rate of 82.1% (46/56). The rates of HPV clearance were observed to be 37.5% (21/56) and 44.6% (25/56) within 6 and 12 months, respectively. The study also revealed that HPV clearance significantly influenced histologic elimination within 6 months (p < 0.001) and histologic regression within 12 months (p < 0.01). Furthermore, premenopausal women exhibited a higher HPV clearance rate compared to postmenopausal women (61.5% vs. 30.0%, p = 0.036). 5-ALA PDT can be considered as an available option for the treatment of lower genital squamous intraepithelial lesions. The efficacy of its histologic response depends on HPV clearance. Additionally, it has been found that premenopausal women may benefit more from this treatment.
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Affiliation(s)
- Yingzhen Liu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, Changsha, Hunan, China
| | - Hekabakila-Banzouzi Medlege
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, Changsha, Hunan, China
| | - Yanan Kang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China
| | - Lisha Wu
- Institute of Medical Sciences, Xiangya Hoapital, Central South University, Changsha, Hunan, China
| | - Wenqing Yang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, Changsha, Hunan, China
| | - Yu Zhang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Yan Tian
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 41008, China.
- Gynecological Oncology Research and Engineering Center of Hunan Province, Changsha, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China.
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Zhao X, Zhang R, Song S, Wang Y, Mu X. Analysis of the clinical characteristics and surgical methods of high-grade squamous intraepithelial lesions of the cervix in postmenopausal women: A retrospective case study. Medicine (Baltimore) 2024; 103:e38657. [PMID: 38905358 PMCID: PMC11191910 DOI: 10.1097/md.0000000000038657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024] Open
Abstract
The purpose of this study was to thoroughly evaluate the clinical features and surgical options for high-grade squamous intraepithelial lesions (HSIL) in postmenopausal women. A total of 308 patients diagnosed with HSIL through colposcopic cervical biopsy and endocervical curettage were included. Their clinical characteristics, surgical treatments, and postoperative pathology were analyzed. Key findings include: 1. Patients with positive preoperative thinprep cytologic test (TCT) results and postoperative pathology indicating HSIL or squamous cell carcinoma (≥HSIL) were significantly more frequent than those with negative preoperative TCT results (P < .05). 2. Univariate analysis indicated significant impacts of TCT, human papillomavirus (HPV) type, transformation zone (TZ) location, and surgical technique on postoperative pathology (P < .05). 3. Logistic regression analysis confirmed significant influences of TCT, HPV type, TZ location, and surgical method on postoperative pathology outcomes (P < .05), showing that each unit increase in TZ raised the probability of ≥HSIL in postoperative pathology by 49.7%. In surgical comparisons, cold knife conization (CKC) and extrafascial hysterectomy resulted in 8.379 and 4.427 times higher probabilities of ≥HSIL in postoperative pathology, respectively, compared to loop electrosurgical excision procedure (LEEP). 4. Surgical methods significantly influenced margin results (P < .05). After LEEP, 17.5% of cases had positive margins, compared to 9.4% after CKC, and 3.7% after extrafascial hysterectomy, indicating the highest rate of positive surgical margins occurred with LEEP. 1. Combined TCT and HPV screening is crucial for cervical cancer prevention, early detection, and management in postmenopausal women. Women with positive results for both TCT and HPV should undergo colposcopic cervical biopsy and endocervical curettage. 2. For patients with TZ3, CKC is the recommended surgical option. 3. CKC is the preferred treatment for postmenopausal women with HSIL, as it effectively diagnoses and treats the lesion, showing superior outcomes in managing postmenopausal HSIL.
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Affiliation(s)
- Xiaofeng Zhao
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Rong Zhang
- Maternal and Child Health Hospital of Inner Mongolia, Hohhot, China
| | - Shufang Song
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yu Wang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiaojie Mu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
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Krog L, Lycke KD, Kahlert J, Randrup TH, Jensen PT, Rositch AF, Hammer A. Risk of progression of cervical intraepithelial neoplasia grade 2 in human papillomavirus-vaccinated and unvaccinated women: a population-based cohort study. Am J Obstet Gynecol 2024; 230:430.e1-430.e11. [PMID: 38569830 DOI: 10.1016/j.ajog.2023.11.1235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 04/05/2024]
Abstract
BACKGROUND Many countries have implemented active surveillance (ie, leaving the lesion untreated) as an option among younger women with cervical intraepithelial neoplasia grade 2 because regression rates are high and excisional treatment increases the risk for preterm birth in subsequent pregnancies. However, early identification of women at increased risk for progression to cervical intraepithelial neoplasia grade 3 or worse is important to ensure timely treatment. Because women who have received a human papillomavirus vaccine have a lower risk for cervical cancer, they may have a lower risk for progression of untreated cervical intraepithelial neoplasia grade 2 to cervical intraepithelial neoplasia grade 3 or worse. OBJECTIVE This study aimed to investigate if women who received a human papillomavirus vaccine and who are undergoing active surveillance for cervical intraepithelial neoplasia grade 2 are less likely to progress to cervical intraepithelial neoplasia grade 3 or worse when compared with women who did not receive the vaccine. STUDY DESIGN We conducted a population-based cohort study in Denmark using data from national health registers. We identified all women aged 18 to 40 years who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 from January 1, 2007, to December 31, 2020. Women with a previous record of cervical intraepithelial neoplasia grade 2 or worse, hysterectomy, or a loop electrosurgical excision procedure were excluded. Exposure was defined as having received ≥1 dose of a human papillomavirus vaccine at least 1 year before the cervical intraepithelial neoplasia grade 2 diagnosis. We used cumulative incidence functions to estimate the risk for progression to cervical intraepithelial neoplasia grade 3 or worse within 28 months using hysterectomy, emigration, and death as competing events. We used modified Poisson regression to calculate crude and adjusted relative risks of progression during the 28-month surveillance period. Results were stratified by age at vaccination and adjusted for index cytology, disposable income, and educational level. RESULTS The study population consisted of 7904 women of whom 3867 (48.9%) were vaccinated at least 1 year before a diagnosis of cervical intraepithelial neoplasia grade 2. At the time of cervical intraepithelial neoplasia grade 2 diagnosis, women who were vaccinated were younger (median age, 25 years; interquartile range, 23-27 years) than those who were not (median age, 29 years; interquartile range, 25-33 years). The 28-month cumulative risk for cervical intraepithelial neoplasia grade 3 or worse was significantly lower among women who were vaccinated before the age of 15 years (22.9%; 95% confidence interval, 19.8-26.1) and between the ages of 15 and 20 years (31.5%; 95% confidence interval, 28.8-34.3) when compared with women who were not vaccinated (37.6%; 95% confidence interval, 36.1-39.1). Thus, when compared with women who were not vaccinated, those who were vaccinated before the age of 15 years had a 35% lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse (adjusted relative risk, 0.65; 95% confidence interval, 0.57-0.75), whereas women who were vaccinated between the ages of 15 and 20 years had a 14% lower risk (adjusted relative risk, 0.86; 95% confidence interval, 0.79-0.95). For women who were vaccinated after the age of 20 years, the risk was comparable with that among women who were not vaccinated (adjusted relative risk, 1.02; 95% confidence interval, 0.96-1.09). CONCLUSION Women who were vaccinated and who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 had a lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse during 28 months of follow-up when compared with women who were not vaccinated but only if the vaccine was administered by the age of 20 years. These findings may suggest that the human papillomavirus vaccination status can be used for risk stratification in clinical management of cervical intraepithelial neoplasia grade 2.
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Affiliation(s)
- Louise Krog
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.
| | - Kathrine D Lycke
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Tina H Randrup
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Pernille T Jensen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Lycke KD, Kahlert J, Eriksen DO, Omann C, Pedersen LH, Sundtoft I, Landy R, Petersen LK, Hammer A. Preterm Birth Following Active Surveillance vs Loop Excision for Cervical Intraepithelial Neoplasia Grade 2. JAMA Netw Open 2024; 7:e242309. [PMID: 38483389 PMCID: PMC10940954 DOI: 10.1001/jamanetworkopen.2024.2309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Active surveillance for cervical intraepithelial neoplasia grade 2 (CIN2) is being implemented in many high-income countries due to the association of excisional treatment with preterm birth. However, it is unknown whether active surveillance results in lower risk of preterm birth given that cervical dysplasia itself is associated with higher risk of preterm birth. Objective To compare the preterm birth risk between women with CIN2 undergoing active surveillance or immediate loop electrosurgical excision procedure (LEEP). Design, Setting, and Participants This historical population-based cohort study included women with a first-time diagnosis of CIN2 and a subsequent singleton birth from 1998 to 2018 in Denmark. Women with prior CIN grade 3 or greater or LEEP were excluded. Data were collected from 4 Danish health care registries. Analyses were conducted from October 2022 to June 2023. Exposure Women were categorized into active surveillance (cervical biopsy and/or cytology) or immediate LEEP based on their first cervical sample after CIN2 diagnosis. The active surveillance group was further subdivided based on whether a delayed LEEP was performed within 28 months from CIN2 diagnosis. Main Outcomes and Measures Risk of preterm birth (<37 + 0 weeks) was assessed and relative risks (RRs) were calculated using modified Poisson regression. Analyses used inverse probability treatment weighting of the propensity scores to adjust for age, parity, calendar year, index cytology, and smoking. Results A total of 10 537 women with CIN2 and a singleton birth were identified; 4430 (42%) underwent active surveillance and 6107 (58%) were treated with immediate LEEP. For both groups, most were aged 23 to 29 years at CIN2 diagnosis (3125 [70%] and 3907 [64%], respectively). Overall, 869 births (8.2%) were preterm. The risk of preterm birth was comparable between active surveillance and immediate LEEP (RR, 1.03; 95% CI, 0.90-1.18). However, for women undergoing delayed LEEP after active surveillance (1539 of the active surveillance group [35%]), the risk of preterm birth was higher than for women treated with immediate LEEP (RR, 1.29; 95% CI, 1.08-1.55). Conclusions and relevance In this cohort study of women with CIN2, the risk of preterm birth was comparable between active surveillance and immediate LEEP. However, delayed LEEP was associated with 30% higher risk of preterm birth than immediate LEEP. Thus, risk stratification at CIN2 diagnosis is important to identify women with increased risk of delayed LEEP.
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Affiliation(s)
- Kathrine Dyhr Lycke
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
- NIDO, Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Dina Overgaard Eriksen
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
- NIDO, Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Camilla Omann
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
- NIDO, Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Henning Pedersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Iben Sundtoft
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rebecca Landy
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
- NIDO, Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Cho A, Kim MY, Park IS, Park CM. A retrospective study for long-term oncologic and obstetric outcomes in cervical intraepithelial neoplasia treated with loop electrosurgical excision procedure: focus on surgical margin and human papillomavirus. BMC Womens Health 2024; 24:116. [PMID: 38347568 PMCID: PMC10863218 DOI: 10.1186/s12905-024-02923-5] [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: 09/19/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The present study aimed to evaluate the long-term oncological and obstetric outcomes following the loop electrosurgical excision procedure (LEEP) in patients with cervical intraepithelial neoplasia (CIN) and investigate the risk factors for recurrence and preterm birth. METHODS This retrospective cohort study included patients who underwent LEEP for CIN 2-3 between 2011 and 2019. Demographic information, histopathological findings, postoperative cytology, and human papillomavirus (HPV) status were collected and analyzed. The Cox proportional hazards model and Kaplan-Meier curves with the log-rank test were used for risk factor analysis. RESULTS A total of 385 patients treated with the LEEP were analyzed. Treatment failure, including recurrence or residual disease following surgery, was observed in 13.5% of the patients. Positive surgical margins and postoperative HPV detection were independent risk factors for CIN1 + recurrence or residual disease (HR 1.948 [95%CI 1.020-3.720], p = 0.043, and HR 6.848 [95%CI 3.652-12.840], p-value < 0.001, respectively). Thirty-one patients subsequently delivered after LEEP, and the duration between LEEP and delivery was significantly associated with preterm-related complications, such as a short cervix, preterm labor, and preterm premature rupture of the membrane (p = 0.009). However, only a history of preterm birth was associated with preterm delivery. CONCLUSIONS Positive HPV status after LEEP and margin status were identified as independent risk factors for treatment failure in patients with CIN who underwent LEEP. However, combining these two factors did not improve the prediction accuracy for recurrence.
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Affiliation(s)
- Angela Cho
- Department of Obstetrics and Gynecology, Jeju National University Hospital, Jeju-si, Republic of Korea.
- Department of Obstetrics and Gynecology, College of Medicine, Jeju National University, Aran 13-gil, Jeju-si, Jeju-do, 63241, Republic of Korea.
| | - Min-Young Kim
- Department of Obstetrics and Gynecology, Jeju National University Hospital, Jeju-si, Republic of Korea
| | - In-Sun Park
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Min Park
- Department of Obstetrics and Gynecology, Jeju National University Hospital, Jeju-si, Republic of Korea
- Department of Obstetrics and Gynecology, College of Medicine, Jeju National University, Aran 13-gil, Jeju-si, Jeju-do, 63241, Republic of Korea
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Chen Q, Zhao J, Xue X, Xie X. Effect of marital status on the survival outcomes of cervical cancer: a retrospective cohort study based on SEER database. BMC Womens Health 2024; 24:75. [PMID: 38281955 PMCID: PMC10822152 DOI: 10.1186/s12905-024-02907-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 01/14/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Cervical cancer is the fourth most common malignant tumor troubling women worldwide. Whether marital status affects the prognosis of cervical cancer is still unclear. Here, we investigate the prognostic value of marital status in patients with cervical cancer based on the seer database. MATERIAL/METHODS The demographic and clinical data of patients with cervical cancer were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017. Patients were divided into two groups (married and unmarried) according to marital status, and then the clinical characteristics of each group were compared using the chi-square test. Propensity score matching (PSM) was used to reduce differences in baseline characteristics. The overall survival (OS) and cervical cancer-specific survival (CCSS) were assessed by the Kaplan-Meier method, univariate and multivariate Cox regression models, and stratified analysis. Moreover, univariate and multivariate competing risk regression models were performed to calculate hazard ratios (HR) of death risk. RESULTS A total of 21,148 patients were included in this study, including 10,603 married patients and 10,545 unmarried patients. Married patients had better OS(P < 0.05) and CCSS (P < 0.05) compared to unmarried patients, and marital status was an independent prognostic factor for both OS (HR: 0.830, 95% CI: 0.798-0.862) and CCSS (HR: 0.892, 95% CI: 0.850-0.937). Moreover, after eliminating the competing risk, married patients (CCSD: HR:0.723, 95% CI: 0.683-0.765, P < 0.001) had a significantly decreased risk of death compared to unmarried patients. In stratified analysis, the married patients showed better OS and CCSS than the unmarried patients diagnosed in 1975-2000 and 2001-2017. CONCLUSIONS Being married was associated with a favorable prognosis of cervical cancer, and marital status was an independent prognostic factor for cervical cancer.
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Affiliation(s)
- Qing Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, P.R. China
| | - Jinyan Zhao
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, P.R. China
| | - Xiang Xue
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, P.R. China.
| | - Xiuying Xie
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, P.R. China.
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Petráš M, Dvořák V, Lomozová D, Máčalík R, Neradová S, Dlouhý P, Malinová J, Rosina J, Lesná IK. Timing of HPV vaccination as adjuvant treatment of CIN2+ recurrence in women undergoing surgical excision: a meta-analysis and meta-regression. Sex Transm Infect 2023; 99:561-570. [PMID: 37553234 PMCID: PMC10715477 DOI: 10.1136/sextrans-2023-055793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE The main aim was to determine the overall vaccine effectiveness (VE) against recurrent cervical intraepithelial neoplasia grade 2 or worse (CIN2+) including specific VE associated with timing of human papillomavirus (HPV) vaccination using data from published studies. DESIGN Meta-analysis and meta-regression. DATA SOURCES A computerised literature search was undertaken using the MEDLINE, EMBASE, International Pharmaceutical Abstracts, Derwent Drug File, ProQuest Science and Technology, Cochrane and MedRxiv databases. To be eligible, the studies, with no language restrictions, had to be published between 1 January 2001 and 25 May 2023. REVIEW METHODS Included were studies with an unvaccinated reference group that assessed CIN2+ recurrence irrespective of the HPV genotype in women undergoing conisation provided. The present study was carried out in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. The risk of study bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. The Grading of Recommendations Assessment, Development, and Evaluation guidelines were used to assess the strength of evidence for the primary outcome. Data synthesis was conducted using meta-analysis and meta-regression. RESULTS Out of a total of 14 322 publications, 20 studies with a total of 21 estimates were included. The overall VE against recurrent CIN2+ irrespective of the HPV genotype achieved 69.5% (95% CI: 54.7% to 79.5%). While the HPV vaccine valency, follow-up duration, type of study including its risk of bias had no effect on VE, the highest VE of 78.1% (95% CI: 68.7% to 84.7%) was reported for women receiving their first dose not earlier than the day of excision. This outcome was supported by additional analyses and a VE prediction interval ranging from 67.1% to 85.4%. CONCLUSIONS The outcome of this meta-analysis and meta-regression convincingly showed the beneficial effect of post-excisional HPV vaccination against CIN2+ recurrence. Studies published to date have been unable to determine whether or not vaccination, completed or initiated before conisation, would be associated with more favourable results. PROSPERO REGISTRATION NUMBER CRD42022353530.
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Affiliation(s)
- Marek Petráš
- Department of Epidemiology and Biostatistics, Charles University, Prague, Czech Republic
| | - Vladimír Dvořák
- Center of Ambulatory Gynecology and Primary Care, Brno, Czech Republic
| | - Danuše Lomozová
- Department of Epidemiology and Biostatistics, Charles University, Prague, Czech Republic
| | - Roman Máčalík
- Department of Epidemiology and Biostatistics, Charles University, Prague, Czech Republic
| | - Sylva Neradová
- Department of Epidemiology and Biostatistics, Charles University, Prague, Czech Republic
| | - Pavel Dlouhý
- Department of Hygiene, Charles University, Prague, Czech Republic
| | - Jana Malinová
- Královské Vinohrady University Hospital, Prague, Czech Republic
| | - Jozef Rosina
- Department of Medical Biophysics and Medical Informatics, Charles University, Prague, Czech Republic
- Department of Health Care and Population Protection, Ceské vysoké ucení technické v Praze Fakulta biomedicinského inzenyrstvi, Kladno, Czech Republic
| | - Ivana Králová Lesná
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Anesthesia, Charles University First Faculty of Medicine, Prague, Czech Republic
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9
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Lycke KD, Kahlert J, Petersen LK, Damgaard RK, Cheung LC, Gravitt PE, Hammer A. Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study. BMJ 2023; 383:e075925. [PMID: 38030154 PMCID: PMC10685285 DOI: 10.1136/bmj-2023-075925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To describe the long term risk of cervical cancer in women with untreated (that is, undergoing active surveillance) or immediately treated cervical intraepithelial neoplasia grade 2 (CIN2). DESIGN Nationwide population based historical cohort study. SETTING Danish healthcare registries. PARTICIPANTS Women with CIN2 diagnosed in 1998-2020 and aged 18-40 years at diagnosis, who had either active surveillance or immediate treatment with large loop excision of the transformation zone (LLETZ). Women with a previous record of CIN2 or worse or LLETZ were excluded. MAIN OUTCOME MEASURE A Weibull survival model for interval censored time-to-event data was used to estimate the cumulative risk of cervical cancer. Inverse probability treatment weighting was used to adjust estimates for age, index cytology, calendar year, and region of residence. RESULTS The cohort included 27 524 women with CIN2, of whom 12 483 (45%) had active surveillance and 15 041 (55%) had immediate LLETZ. During follow-up, 104 cases of cervical cancer were identified-56 (54%) in the active surveillance group and 48 (46%) in the LLETZ group. The cumulative risk of cervical cancer was comparable across the two groups during the active surveillance period of two years. Thereafter, the risk increased in the active surveillance group, reaching 2.65% (95% confidence interval 2.07% to 3.23%) after 20 years, whereas it remained stable in the LLETZ group at 0.76% (0.58% to 0.95%). CONCLUSIONS Undergoing active surveillance for CIN2, thereby leaving the lesion untreated, was associated with increased long term risk of cervical cancer compared with immediate LLETZ. These findings show the importance of continued follow-up of women having active surveillance.
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Affiliation(s)
- Kathrine Dyhr Lycke
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynaecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Kamp Damgaard
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Patti E Gravitt
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA
| | - Anne Hammer
- Department of Obstetrics and Gynaecology, Gødstrup Hospital, Herning, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Boisen M, Guido R. Emerging Treatment Options for Cervical Dysplasia and Early Cervical Cancer. Clin Obstet Gynecol 2023; 66:500-515. [PMID: 37650664 DOI: 10.1097/grf.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
DISCUSSION of treatment strategies for cervical cancer precursors, review of medical therapies and emerging therapeutics for treatment of cervical cancers, and updates on new approaches to treating early-stage cervical cancers.
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Affiliation(s)
- Michelle Boisen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
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11
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Cortés Bordoy J, de Santiago García J, Agenjo González M, Dexeus Carter D, Fiol Ruiz G, García Ferreiro C, González Rodríguez SP, Gurrea Soteras M, Martínez Lamela E, Palacios Gil-Antuñano S, Romo de los Reyes JM, Sanjuán Cárdenas MDP, Serrano Cogollor L, del Villar Vázquez AE. Effect of a Multi-Ingredient Coriolus-versicolor-Based Vaginal Gel in Women with HPV-Dependent Cervical Lesions: The Papilobs Real-Life Prospective Study. Cancers (Basel) 2023; 15:3863. [PMID: 37568678 PMCID: PMC10417075 DOI: 10.3390/cancers15153863] [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: 04/04/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Human papillomavirus (HPV) is responsible for virtually all cervical cancers in women. HPV infection and persistency may lead to different-grade squamous intraepithelial lesions that can result in high-grade lesions and cancer. The objective was to prospectively evaluate the results of using a Coriolus-versicolor-based vaginal gel (Papilocare®) on HPV-dependent low-grade cervical lesion repair in a real-life scenario. HPV-positive women ≥ 25 years with ASCUS/LSIL cervical cytology results and concordant colposcopy images were included, receiving the vaginal gel one cannula/day for 21 days (first month) + one cannula/alternate days (five months). A 6-month second treatment cycle was prescribed when needed. Repair of the cervical low-grade lesions through cytology and colposcopy, HPV clearance, and level of satisfaction, and tolerability were evaluated. In total, 192 and 201 patients accounted for the total and safety analyses, respectively, and 77.1% repaired cervical lesions at 6 or 12 months (76.0% for high-risk HPV). Additionally, 71.6% achieved HPV clearance throughout the study's duration (70.6% for high-risk HPV). Satisfaction level was rated 7.9 and 7.5 out of 10 at 6 and 12 months, respectively. Only three mild-moderate product-related adverse events were reported, and all of them were resolved by the end of the study. In our study, we observed higher regression rates of low-grade cervical lesions in women treated with Papilocare® vaginal gel than spontaneous regression rates reported in the literature.
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Affiliation(s)
- Javier Cortés Bordoy
- Gynecologic Oncology, Private Practice (Laboratorio citología Dr. Cortés), 07004 Palma, Spain
| | | | - Marta Agenjo González
- Cervical Pathology Unit, Gynaecology Department, Hospital Sanitas La Zarzuela (Madrid), 28006 Madrid, Spain
| | | | | | | | | | - Marta Gurrea Soteras
- Oncologic Gynecology, Lower Genital Tract Unit, Women’s Health Area, Hospital Universitari i Politécnic La Fe Valencia, 46026 Valencia, Spain;
| | - Ester Martínez Lamela
- Lower Genital Tract & Endoscopic Gyneacology Unit, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain;
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12
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Dovnik A, Poljak M. The Role of Methylation of Host and/or Human Papillomavirus (HPV) DNA in Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) Lesions. Int J Mol Sci 2023; 24:ijms24076479. [PMID: 37047452 PMCID: PMC10095339 DOI: 10.3390/ijms24076479] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN2) is an intermediate stage between CIN 1, which is a low-grade lesion, and CIN3, which is the immediate precursor of cervical cancer (CC). Traditionally, CIN2 was regarded as a high-grade lesion and was treated with conization or ablative methods. In recent years, there has been a shift in the management of younger patients, who are now more often being managed conservatively due to frequent spontaneous CIN2 regression and possible adverse effects of treatment on future pregnancies. Because the risk of progression to CC still exists with conservative management, a personalized approach is needed to identify patients with a higher probability of progression. In this regard, research has focused on the role of host and human papillomavirus (HPV) gene methylation. This systematic review summarizes the current knowledge regarding conservative CIN2 management focusing on the main methylation markers and its implementation in conservative CIN2 management, and it describes major ongoing longitudinal studies on the subject. The review showed that DNA methylation is an accurate predictor of disease progression and a valid triage tool for HPV-positive women, with CIN2 performing better than triage cytology. Because virtually all CCs are methylation-positive, methylation-negative women at baseline have an extremely low risk of CC.
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Affiliation(s)
- Andraž Dovnik
- University Clinic for Gynecology and Obstetrics, Maribor University Medical Center, Ljubljanska 5, 2000 Maribor, Slovenia
- Correspondence: ; Tel.: +386-2-321-2178
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia;
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13
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Stefanovic S, Mitic IS, Sütterlin M, WEIß C, Spaich S. Operator Sex and Experience Do Not Influence Conization Outcomes in Terms of Cone Volume, Depth or Resection Margins. In Vivo 2023; 37:841-847. [PMID: 36881101 PMCID: PMC10026644 DOI: 10.21873/invivo.13151] [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: 01/20/2023] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND/AIM Conization in patients with cervical intraepithelial neoplasia is associated with longer time required to conceive, a higher risk of preterm delivery, and a myriad of obstetric complications. This study assessed whether operator sex and experience correlate with cone volume, depth, and resection margins in patients wishing to conceive and the general patient population. PATIENTS AND METHODS This retrospective single center cohort study included 141 women who had undergone conization for cervical dysplasia in 2020 and 2021. Loop size selection was guided by the preoperative colposcopy report and intraoperative diluted Lugol staining. The hemiellipsoid cone volume was compared for subgroups in three categories: patients operated on by residents vs. board-certified gynecologists; patients operated on by female vs. male surgeons; patients who wished to pursue future pregnancy after conization vs. those who did not. RESULTS Female surgeons excised insignificantly less cervical tissue compared with their male counterparts (p=0.08). In the subgroup of patients without the wish to conceive, male surgeons tended to excise significantly bigger volumes during conization (p=0.008). No significant difference (p=0.74) regarding volume of resected tissue was evidenced when comparing residents to board-certified surgeons, both in patient subgroups with (p=0.58) and without (p=0.36) a wish to conceive. Male surgeons tended to resect higher volumes (p=0.012) if board-certified compared to their board-certified female colleagues. CONCLUSION There were insignificant differences regarding cone depth and volume or incomplete resection when stratified by operator experience and sex. However, male gynecologists removed significantly larger cone volumes in the subgroup of patients who did not pursue future pregnancy.
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Affiliation(s)
- Stefan Stefanovic
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany;
| | - Iva Stefanovic Mitic
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Christel WEIß
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Saskia Spaich
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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14
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Kechagias KS, Kalliala I, Bowden SJ, Athanasiou A, Paraskevaidi M, Paraskevaidis E, Dillner J, Nieminen P, Strander B, Sasieni P, Veroniki AA, Kyrgiou M. Role of human papillomavirus (HPV) vaccination on HPV infection and recurrence of HPV related disease after local surgical treatment: systematic review and meta-analysis. BMJ 2022; 378:e070135. [PMID: 35922074 PMCID: PMC9347010 DOI: 10.1136/bmj-2022-070135] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To explore the efficacy of human papillomavirus (HPV) vaccination on the risk of HPV infection and recurrent diseases related to HPV infection in individuals undergoing local surgical treatment. DESIGN Systematic review and meta-analysis DATA SOURCES: PubMed (Medline), Scopus, Cochrane, Web of Science, and ClinicalTrials.gov were screened from inception to 31 March 2021. REVIEW METHODS Studies reporting on the risk of HPV infection and recurrence of disease related to HPV infection after local surgical treatment of preinvasive genital disease in individuals who were vaccinated were included. The primary outcome measure was risk of recurrence of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) after local surgical treatment, with follow-up as reported by individual studies. Secondary outcome measures were risk of HPV infection or other lesions related to HPV infection. Independent and in duplicate data extraction and quality assessment were performed with ROBINS-I and RoB-2 tools for observational studies and randomised controlled trials, respectively. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was implemented for the primary outcome. Observational studies and randomised controlled trials were analysed separately from post hoc analyses of randomised controlled trials. Pooled risk ratios and 95% confidence intervals were calculated with a random effects meta-analysis model. The restricted maximum likelihood was used as an estimator for heterogeneity, and the Hartung-Knapp-Sidik-Jonkman method was used to derive confidence intervals. RESULTS 22 articles met the inclusion criteria of the review; 18 of these studies also reported data from a non-vaccinated group and were included in the meta-analyses (12 observational studies, two randomised controlled trials, and four post hoc analyses of randomised controlled trials). The risk of recurrence of CIN2+ was reduced in individuals who were vaccinated compared with those who were not vaccinated (11 studies, 19 909 participants; risk ratio 0.43, 95% confidence interval 0.30 to 0.60; I2=58%, τ2=0.14, median follow-up 36 months, interquartile range 24-43.5). The effect estimate was even stronger when the risk of recurrence of CIN2+ was assessed for disease related to HPV subtypes HPV16 or HPV18 (six studies, 1879 participants; risk ratio 0.26, 95% confidence interval 0.16 to 0.43; I2=0%, τ2=0). Confidence in the meta-analysis for CIN2+ overall and CIN2+ related to HPV16 or HPV18, assessed by GRADE, ranged from very low to moderate, probably because of publication bias and inconsistency in the studies included in the meta-analysis. The risk of recurrence of CIN3 was also reduced in patients who were vaccinated but uncertainty was large (three studies, 17 757 participants; 0.28, 0.01 to 6.37; I2=71%, τ2=1.23). Evidence of benefit was lacking for recurrence of vulvar, vaginal, and anal intraepithelial neoplasia, genital warts, and persistent and incident HPV infections, although the number of studies and participants in each outcome was low. CONCLUSION HPV vaccination might reduce the risk of recurrence of CIN, in particular when related to HPV16 or HPV18, in women treated with local excision. GRADE assessment for the quality of evidence indicated that the data were inconclusive. Large scale, high quality randomised controlled trials are required to establish the level of effectiveness and cost of HPV vaccination in women undergoing treatment for diseases related to HPV infection. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021237350.
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Affiliation(s)
- Konstantinos S Kechagias
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Ilkka Kalliala
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sarah J Bowden
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Antonios Athanasiou
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Maria Paraskevaidi
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | | | - Joakim Dillner
- Centre for Cervical Cancer Prevention, Medical Diagnostics Karolinska, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Pekka Nieminen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bjorn Strander
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Sasieni
- King's Clinical Trials Unit, King's College London, London, UK
| | - Areti Angeliki Veroniki
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Maria Kyrgiou
- Department of Metabolism, Digestion, and Reproduction and Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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