Prevention of Cervical Cancer: Guideline of the DGGG and the DKG (S3 Level, AWMF Register Number 015/027OL, December 2017) - Part 1 with Introduction, Screening and the Pathology of Cervical Dysplasia

Impact of the Corona Pandemic on Cervical Cancer Screening Assessment

BACKGROUND/AIM

The global impact of the COVID-19 pandemic resulted in disruptions to healthcare systems throughout the world. The numbers of cytology examinations, human papillomavirus (HPV) tests, and women referred for colposcopy decreased in many countries. There have been no reports on cervical cancer screening in Germany. This study aimed to describe changes in the numbers of colposcopies, cytology examinations, HPV tests, and histological results during the pandemic compared to the pre-pandemic years in order to evaluate the impact of the COVID-19 pandemic on cervical cancer screening.

PATIENTS AND METHODS

The numbers of colposcopies, cytology examinations, HPV tests, and histologic results were analyzed retrospectively for the period January 2018 to December 2022. The 2 years period before the pandemic (2018 and 2019) were compared with the 3 years period of the pandemic (2020-2022).

RESULTS

In total, 6,518 colposcopies were performed in 5,579 women. The numbers of colposcopies, cytology examinations, and high-risk HPV (hrHPV) tests increased during the pandemic years. The number of biopsies per year taken was stable (range=450-554). The relative numbers of cervical intraepithelial neoplasia (CIN) III/HSIL findings were stable, while the numbers of cervical cancers identified increased slightly from 15 (6.6%) in 2018 to 22 (7.4%) in 2022.

CONCLUSION

Increases in numbers of women examined and colposcopies were observed in the years 2021 and 2022 during the pandemic, in comparison to the preceding years. These also led to increases in the figures for cytology, hrHPV, histology, and operations. The onset of the pandemic occurred in the same year as a newly organized screening program started in Germany. The increases might therefore be due to the newly organized screening system.

Evaluations of the 2019 Annual Statistics Under the Cervical Cytology Quality Assurance Agreement: 2019 Annual Statistics for Cervical Cytology from 15608413 Women

Background

Cervical cancer screening, which was introduced into the programme of medical care covered by statutory health insurance in Germany in 1971 and has since been constantly updated through quality assurance measures, was fundamentally revised and developed in 2008 through the Cervical Cytology Quality Assurance Agreement pursuant to Section 135(2) of the German Social Code Book V [SGB V]. Since 2015 it has been mandatory for cytology facilities to record annual statistics based on the Munich Nomenclature III. The aim of this article is to present the results of the annual statistics for 2019, which was the last year before the introduction of the cervical cancer screening programme in accordance with the Federal Joint Committee's guideline on organised cancer screening programmes 1 .

Materials and Methods

The annual statistics of the laboratories, including histology analyses performed up until 30 June the following year, are reported to the Regional Associations of Statutory Health Insurance Physicians. The laboratories receive benchmark reports from their Regional Associations of Statutory Health Insurance Physicians, and these statistics are transmitted anonymously to the National Association of Statutory Health Insurance Physicians (KBV).

Results

In 2019, 17609082 smears from 15608413 women were examined in Germany. Of these smears, 97.49% were normal and 2.51% showed atypical or suspicious changes, consisting mostly of minor squamous epithelial changes in groups II-p (0.81%) and IIID1 (0.735%).Histology specimens are available for "Dysplasia findings with higher probability of regression" in group IIID1 (4.89% of initial IIID1 cytology findings), group IIID2 (18.60%), "unclear or doubtful findings" in group III-p to x (20.7%), and "immediate precursors to cervical carcinoma" in group IV (83.1%) and group V (77.19%).In the cytology findings for group IVa-p, which corresponds to CIN 3 target lesions, the cytology correlated with the histology finding in 80.48% of cases.Lesions found in 2019: 23463 CIN 3 lesions, 668 adenocarcinomas in situ, 3891 malignant tumours, including 2342 cervical carcinomas of which 1743 were squamous cell carcinomas and 599 were cervical adenocarcinomas (25.57%); 1549 endometrial carcinomas and other malignancies.

Inference/Conclusion

The data demonstrate the good practicability of cervical cancer screening in 2019. Higher grade lesions were reliably clarified histologically.

Standardized Procedures for Patients with Dysplasia and Other Diseases of the Cervix, Vulva, and Vagina at a Certified Dysplasia Unit Prior to the Introduction of the Organized Cervical Cancer Screening Program

Introduction Gynecologic dysplasia units and dysplasia consultations are obliged to offer diagnosis and treatment in accordance with the guidelines. The organization of the consultation process, management of patient appointments, diagnosis, and treatment algorithms are heterogeneous. The legislation arising from the new Federal Joint Committee decision, dated 22 November 2018, concerning the organized cervical cancer screening program has been in force since 1 January 2020. In this article we provide an overview of the existing structures and interdisciplinary cooperation of specialized dysplasia units incorporated in certified gynecologic cancer center. Materials and Methods We carried out a retrospective database search of data collected prospectively from 1 July 2014 to 31 December 2019 at the dysplasia unit at the Department of Gynecology and Obstetrics, Erlangen University Hospital, which was the first dysplasia unit to be certified in 2014. Results A total of 5594 patients presented at the unit, and 16061 colposcopic, vulvoscopic, and anoscopic examinations were performed. Approximately 4100 examinations of the cervix, vagina, vulva, and anus are carried out each year, 1600 of these were exclusively cervix colposcopies. A total of 12197 cytology results were assessed, as well as 4850 histology results, and 8193 high-risk HPV tests. The quality indicators required by the dysplasia unit for annual recertification were met each year. Conclusion Certified dysplasia units and consultations form the central component in the algorithm for further investigating abnormal screening results; but they are also the first point of contact for a large number of patients with acute or chronic complaints in the genital region.

Evaluation of the clinical performance of OncoPredict HPV® SCR assay within the VALGENT-2 framework

Human papillomavirus (HPV) assays used in cervical cancer screening should be clinically validated according to international criteria. OncoPredict HPV® Screening (SCR) is a partial genotyping multiplex real-time PCR assay targeting E6/E7 genes of 13 high-risk (hr) HPVs. OncoPredict HPV® SCR (index assay) identifies HPV-16 and HPV-18 separately, 11 other hrHPV in aggregate and includes quality controls for sample adequacy, DNA extraction efficiency and PCR inhibition. 1300 VALGENT-2 study samples (from women aged 20-60 attending the Scottish cervical cancer screening program) were tested with the index assay and the GP5+/6+ PCR enzyme immunoassay (standard comparator assay). Non-inferior accuracy detecting cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) of the index versus comparator was verified. Intra- and interlaboratory reproducibility of the index was evaluated by overall concordance and Cohen's kappa, using a sub-population (n = 526). Relative sensitivity and specificity for CIN2+ of the index versus comparator were 1.01 (95% confidence interval [CI]: 0.99-1.03) and 1.02 (95% CI: 1.0-1.04), respectively. Noninferiority p values were all ≤0.05, except for CIN3+ in patients ≥30 years. Excellent intra- and interlaboratory reproducibility was shown with concordance >98% and kappas >0.95. OncoPredict HPV® SCR fulfills the three international validation criteria for hrHPV DNA tests in cervical cancer screening.

COVID-19 can lead to rapid progression of cervical intraepithelial neoplasia by dysregulating the immune system: A hypothesis

COVID-19 is a multisystem disease and cause of a global pandemic. Lately, cases of disease progression of HPV-infected CIN under SARS-CoV-2 infection were reported giving rise to the hypothesis of direct virus-infection induced pro-carcinogenic effect of SARS-CoV-2. We herein present a case of rapid progression from HPV-induced CIN 2 to microinvasive carcinoma within three months under COVID-19 without direct virus infection. Histopathologic evaluation, Fluorescence-in-situ hybridization and qRT-PCR against SARS-CoV-2 RNA as well as gene expression analysis were performed from the available FFPE-tissue and accompanied by an analysis of white blood cell differential. No signs of direct SARS-CoV-2 infection or COVID-19 typical alterations of cervical tissue were found. As expected, p53 decreased in expression with progression of dysplasia, while APOBEC3A and VISTA showed a decrease in expression contrary to observations in dysplasia progression. PD-L1 was expressed consistently or increased slightly but did not show the expected strong induction of expression. DNMT1 showed an increase in expression in CIN III and a slight decrease in carcinoma, while DNMT3a is consistently expressed in CIN II and decreased in carcinoma. Blood tests after COVID-19 showed substantial reduction of lymphocytes, eosinophils, T-cells, and NK-cells. Our results hint at an indirect effect of COVID-19 on the cervical neoplasm. We conclude that the immune system might be preoccupied and exhausted by the concurring COVID-19 disease, leading to less immunological pressure on the HPV-infected cervical dysplasia enabling rapid disease progression. Further, indirect proangiogenic and proinflammatory micromilieu due to the multisystemic effects of COVID-19 might play an additional role.

Risk Factors of Preterm Birth in Women After Local Treatment of Cervical Intraepithelial Neoplasia – a Retrospective Cohort Study

Purpose A previous cervical intraepithelial neoplasia is associated with an increased obstetrical risk. It was the aim of the study to identify risk factors of preterm birth in patients with cervical intraepithelial neoplasia in dependence of the treatment modality (excisional vs. ablative).

Methods Women with treated cervical intraepithelial neoplasia and subsequent pregnancy (n = 155) were included in this retrospective study. Methods of treatment were either conization by large loop excision of the transformation zone (LLETZ) or ablative laser vaporization.

Results Of the total population 60.6% (n = 94) had a conization and 39.4% (n = 61) a laser vaporization alone. The frequency of preterm birth < 37 weeks was 9.7% (n = 15) without differences between conization and laser (11.7 vs. 6.7%, p = 0.407) with an odds ratio (OR) of 1.9 (95% confidence interval [CI] 0.6–6.2). Preterm birth < 34 weeks was found in 2.6% (n = 4), of which all had a conization (4.3 vs. 0%, p = 0.157). Risk factors for preterm birth were repeated cervical intervention (OR 4.7 [95% CI 1.5–14.3]), especially a combination of conization and laser ablation (OR 14.9 [95% CI 4.0–55.6]), age at intervention < 30 years (OR 6.0 [95% CI 1.3–27.4]), a history of preterm birth (OR 4.7 [95% CI 1.3–17.6]) and age at delivery < 28 years (OR 4.7 [95% CI 1.5–14.3]).

Conclusion The large loop excision of the transformation zone as a modern, less invasive ablative treatment did not obviously increase the risk of preterm birth compared to laser vaporization. The most important risk factor for preterm delivery was the need of a repeated intervention, especially at younger age. We assume that the persistence or recurrence of the cervical intraepithelial neoplasia following a high-risk human papillomavirus infection is mainly responsible for the observed effect.

Concordance Rate of Colposcopy in Detecting Cervical Intraepithelial Lesions

Background: The purpose of this research is to estimate the rate of concordance, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of colposcopy for high-grade squamous lesions and carcinomas (HSIL+). Methods: We conducted a retrospective study of colposcopies performed in the certified Dysplasia Unit in Erlangen between January 2015 and May 2022 (7.5 years). The colposcopic findings were correlated with biopsies obtained during examinations or surgery. Cases without histology were excluded. The primary outcome was the rate of concordance between the colposcopic and histological findings in relation to the type of transformation zone (TZ), examiner’s level of experience and age of the patients. Results: A total of 4778 colposcopies in 4001 women were analyzed. The rates of concordance for CIN I/LSIL, CIN II/HSIL, CIN III/HSIL, and carcinoma were 43.4%, 59.5%, 78.5%, and 53.9%, respectively. The rate of concordance was lowest for TZ3 and highest for colposcopists with more than 10 years’ experience. Conclusions: Colposcopy is an important, feasible, and effective method. Careful work-up needs to be performed for women with TZ3 who are over 35 years old, as they are at the highest risk of being misdiagnosed. The highest concordance for detecting HSIL+ was seen for colposcopists with >10 years’ experience.

Two Years of Cytology and HPV Co-Testing in Germany: Initial Experience

Introduction On 1 January 2020 the screening programme for the prevention of cervical cancer in women from the age of 35 years of the Statutory Health Insurance (GKV) in Germany changed from an annual cytology examination to cytological and HPV co-testing carried out every three years. A large standard diagnostics laboratory has been using liquid-based cytology (LBC) with computer-assisted screening (CAS) since 1 January 2020 to assess the samples.

Patients and Methods The cytological and HPV results for all cases examined with co-testing from 01.01.2020 to 31.12.2021 (n = 395759) are reported and the cytology results obtained using co-testing are compared with the results obtained using only conventional primary cytology screening from the two previous years (n = 588192). Cytology tests were carried out using LBC and computer-assisted screening. A DNA PCR test which can identify 14 types of HPV was used for HPV testing. The cytology results are reported using the Munich Nomenclature III, which is mandatory in Germany, and converted to The Bethesda System (TBS). Problems occurring during the implementation phase are described here.

Results A total of 983951 cases who had primary screening between 01.01.2018 and 31.12.2021 were analysed. The HR HPV-positive rate with co-testing for all age groups was 6.41%. Of this group, 16.31% were positive for HPV-16, 4.43% for HPV-18, and 71.40% had one or more of the other 12 HR HPV types. Several different HPV types were identified in 7.86% of cases. The HPV-positive rate for cases with unremarkable cytological findings was 4.03%. 0.46% of tests were technically invalid. The results of primary cytology screening for 2020/21 (LBC) were: Pap 0 (TBS: unsatisfactory) 0.09%, Pap I and Pap II-a (NILM) 96.82%, Pap II-p/g (~ASC-US/AGC) 1.23%, Pap III-p/g (~ASC-H/AGC) 0.19%, Pap III D1 (LSIL) 1.08%, Pap III D2 (HSIL) 0.31%, Pap IVa/b-p/g (HSIL/AIS) 0.18%, and Pap V-p/g (carcinoma) 0.01%. The rates for 2018/19 (conventional cytology without routine testing for HPV) were significantly higher for Pap II-p/g (1.64%) and significantly lower for Pap III-p/g (0.13%), Pap III D1 (0.45%), Pap III D2 (0.10%) and Pap IVa/b-p/g (0.05%).

Conclusion Evaluation of the data for the two first years of cytology and HPV co-testing from a standard diagnostics laboratory found low HR HPV-positive rates. As regards the cytology tests, the Pap II-p/g rate was significantly lower and the ≥ Pap III rate was significantly higher compared to the two previous years. This points to a probable higher sensitivity and specificity of the new method.

Cytology and High-Risk Human Papillomavirus Test for Cervical Cancer Screening Assessment

Background: A new nationwide screening strategy was implemented in Germany in January 2020. No data are available for women referred to certified dysplasia units for secondary clarification after primary diagnosis by a local physician. We therefore investigated combined testing with Papanicolaou smears and high-risk human papillomavirus (hrHPV) and compared the data with the final histological findings. Methods: Between January 2015 and October 2020, all referred women who underwent colposcopy of the uterine cervix in our certified dysplasia unit were included. Cytology findings were classified using the Munich III nomenclature. Results: A total of 3588 colposcopies were performed in 3118 women, along with Pap smear and hrHPV co-testing, followed by histology. Women with Pap II-p (ASC-US) and a positive hrHPV co-test had a 22.4% risk for cervical intraepithelial neoplasia (CIN) 3/high-grade squamous intraepithelial lesion (HSIL). The risk of CIN 3/HSIL was 83.8% in women with Pap IVa-p (HSIL) and a positive hrHPV co-test. A positive hrHPV co-test increased the risk for HSIL+ (OR 5.942; 95% CI, 4.617 to 7.649; p < 0.001) as compared to a negative hrHPV co-test. Conclusions: The accuracy of Pap smears is comparable with the screening results. A positive hrHPV test increases the risk for HSIL+ fivefold. Colposcopy is necessary to diagnose HSIL+ correctly.

Cervical Cancer Prophylaxis—State-of-the-Art and Perspectives

Background: Each year 604,127 new cases of cervical cancer (CC) are diagnosed, and 341,831 individuals die from the disease. It is the fourth most common cancer among women and the fourth most common cause of death from female cancers worldwide. The pathogenesis of CC is associated with human papillomavirus (HPV) infections and consists of several steps involving cell proliferation outside the human body’s control mechanisms. Strategies to prevent CC are based on screening and vaccination. Scope of the Review: The aim of this paper was to collect and analyze the available literature on the issue of CC prevention and the impact of the COVID-19 pandemic on its implementation. For this purpose, PubMed and Google Scholar databases were searched using keywords, such as “cervical cancer”; “HPV”; “prevention”; “prophylaxis”; “vaccination”; “screening” and “COVID-19” in different variations. Only articles published since 2018 were included in the study. Conclusions: Selected European countries have different CC prevention programs funded by national budgets. This translates into observed differences in the risk of death from CC (age-standardized rate Malta = 1.1, Poland = 5.9). COVID-19 pandemic due to disruption of CC screening may exacerbate these differences in the future. To improve the situation, new screening methods, such as p16/Ki67, HPV self-testing, and the use of artificial intelligence in colposcopic assessment, should be disseminated, as well as free HPV vaccination programs implemented in all countries. The search for new solutions is not without significance and entails ultra-sensitive screening tests for risk groups (mRNA E6/E7, SOX1/SOX14), HPV vaccines with shorter dosing schedules, and new therapeutic pathways using nanotheranostics.

CoCoss-Trial: Concurrent Comparison of Self-Sampling Devices for HPV-Detection

High-risk human papillomavirus (hr-HPV) infection of the cervicovaginal tract is known to be the major cause of cervical cancer. Similar to various other countries, Germany introduced an organized combined screening including cytology and HPV testing in 2020. The participation rate was around 70% in the past. Self-testing for hr-HPV infections could be an option to increase the participation rate. Two dry vaginal self-sampling devices and a device for the self-collection of first-void urine were evaluated in combination with a PCR-based hr-HPV test regarding their clinical performance (sensitivity for high-grade cervical intraepithelial neoplasia, CIN 2+). A cervical smear taken by a clinician during colposcopy was used as reference. This open prospective multicenter trial recruited patients referred to the two participating colposcopy clinics (Hannover Medical School and IZD Hannover, Germany) with abnormal results from cervical cancer screening from 05/2020 to 11/2020. All patients received three CE-certified self-sampling devices (FLOQSwabs, COPAN, Italy; Evalyn Brush, Rovers Medical Devices, the Netherlands; Colli-Pee FV-5000, Novosanis, Wijnegem, Belgium) with instructions to read and apply at home in a pre-specified alternating order without medical assistance. HPV testing was performed after adequate preservation and DNA extraction. Histological results from colposcopy or cervical excisional surgery after self-sampling were used as the gold-standard. The data of 65 patients were analyzed. All invasive cancer cases and over 90% of the CIN 3 lesions were found to be hr-HPV positive with all three self-collection devices. All devices were considered easy to use without any difficulties following the written instructions. Hr-HPV testing of self-collected first-void urine and dry vaginal self-samples showed a high sensitivity for CIN 3+ comparable to that of a clinician-taken smear. Self-sampling was well accepted as it is convenient and easy to use.

Natural history of histologically confirmed high-grade cervical intraepithelial neoplasia during pregnancy: meta-analysis

OBJECTIVES

This study aimed to conduct a meta-analysis of estimates of the natural history of high-grade cervical intraepithelial neoplasia (CIN) during pregnancy.

SETTING

Studies examining the clinical courses of histologically confirmed high-grade CIN during pregnancy.

PARTICIPANTS

We searched PubMed, Web of Science and Embase for eligible studies. Studies were included if they reported the data regarding the natural history of histologically confirmed high-grade CIN during pregnancy. Final estimates were from the meta-analysis of 10 eligible studies.

PRIMARY OUTCOME MEASURES

The regression rate, persistence rate and progression rate of histologically proven untreated high-grade CIN during pregnancy.

RESULTS

A total of 10 original studies were included in this meta-analysis. During pregnancy, the regression rate, persistence rate and progression rate of high-grade CIN were 40% (95% CI 35% to 45%), 59% (95% CI 54% to 64%) and 1% (95% CI 0% to 2%), respectively. There was moderate heterogeneity among the studies. The results of the subgroup meta-analysis show that the pooled rates of regression and persistence during pregnancy were 59% (95% CI 54% to 65%) and 40% (95% CI 35% to 45%) for CIN2, and 29% (95% CI 25% to 33%) and 70% (95% CI 65% to 73%) for CIN3.

CONCLUSIONS

During pregnancy, the majority of histologically confirmed high-grade CIN would be persistent or regressed to lower grade CIN or normal. However, it is still worth noting that a small percentage of high-grade CIN would progress to cervical cancer during pregnancy.

Human papilloma virus genotype distribution in women with premalignant or malignant lesions of the uterine cervix

OBJECTIVE

Cervical cancer is caused by persistent infection with high-risk human papillomavirus (hrHPV). Cytology-based national screening programs have reduced the incidence and mortality of cervical cancer. Different hrHPV subtypes have different carcinogenic potentials. This study evaluated the distribution of different types of hrHPV relative to age in cervical cancer and its precursor lesions.

METHODS

HPV testing was performed between November 2018 and February 2020 using the Abbott RealTime high-risk HPV assay on an Abbott m2000sp instrument. This assay separately detects HPV-16, HPV-18, and a pool of 12 additional hrHPV types (HPV-31, -33, -35, -39, -45, -51, -52, -56, -58, -59, -66, and -68).

RESULTS

The study included 652 women with HPV samples and biopsies of the cervix or histology samples obtained during surgery. In all, 30.8% (95% CI, 27.3-34.6%) were HPV-negative. Among HPV-positive women, HPV-16, HPV-18, and "HPV other" types were found in 33.5, 4.4, and 49.4%, respectively. Cervical intraepithelial neoplasia (CIN) 3/high-grade squamous intraepithelial lesions (HSILs) in women ≤ 34 years were positive for HPV-16 in 54.5% of cases and in those ≥ 35 years in 45.4% of cases. Among women with cervical cancer, 75.8% were infected with HPV-16 or had coinfection with HPV-16 and "HPV other".

CONCLUSIONS

HPV-16 is the most common type of hrHPV in HSIL + lesions. It is more common in women diagnosed with CIN 3/HSIL who are aged ≤ 35 and is decreasing with age. Therefore, women age ≥ 35 with persistent infection with this type of hrHPV need careful surveillance, as they are at high risk of progression to cervical cancer.

Music-based interventions for pain relief in patients undergoing hemodialysis: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Music therapy and music-based interventions have been used widely in numerous medical procedures to reduce the physical and psychological disorders. However, the effect of music therapy on pain relief in hemodialysis patients still remains unclear.

METHODS

Electronic databases were comprehensively searched through MEDLINE, Web of Science, EMBASE, Cochrane, and WANFANG. All studies met inclusion criteria were eligible for systematic review and meta-analysis. Clinical variables were extracted and pooled results were obtained using STATA software.

RESULTS

A total of 10 studies with 722 participants were included for systematic review. Overall, music therapy showed a significantly favorable effect on reducing pain for patients undergoing hemodialysis (SMD: -0.90, 95%CIs: -1.25 to -0.55, P < .001). No publication bias was observed.

CONCLUSIONS

Music-based interventions could significantly relieve pain for patients undergoing hemodialysis, which should be promoted as an effective and safe complementary method.

Analysis of Oncological Second Opinions in a Certified University Breast and Gynecological Cancer Center Regarding Consensus between the First and Second Opinion and Conformity with the Guidelines

Introduction

Oncological second opinions are becoming increasingly important in the era of complex treatments and established certified cancer centers. Oncological guidelines with the highest levels of evidence are available, but these can only be effective to the extent that they are implemented. Therefore, we analyzed the effects of second opinions with regard to their agreement with first opinions and conformity with guidelines.

Methods

In 164 patients with a diagnosis of breast cancer or gynecological malignancy who requested a second opinion, the first and second opinions, established at the interdisciplinary tumor conference, and conformity with the guidelines were evaluated.

Results

The first opinion was not in agreement with the guidelines in 34.8% (15.2% diagnosis, 12.8% surgical therapy, 13.4% systemic therapy, and 5.5% radiotherapy), and the recommendations were optimized in the second opinion in 56.7% (28.7% diagnosis, 15.9% surgical therapy, 30.5% systemic therapy, and 8.5% radiotherapy).

Conclusions

Oncological second opinions showed significant effects and one-third of first opinions were not in conformity with the guidelines. In a significant proportion of cases, the existing treatment plan was changed or supplemented to allow modern and individualized treatment approaches.

Prophylactic HPV vaccination after conization: A systematic review and meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination is essential for cervical cancer prevention. However, the value of HPV vaccination in the context excisional treatment of high-grade cervical intraepithelial neoplasia (CIN 3) remains unclear.

METHODS

In this meta-analysis, three retrospective and three prospective studies, three post-hoc analyses of RCTs and one cancer registry study analysing the effect of pre- or post-conization vaccination (bi- or quadrivalent vaccine) against HPV were included after a systematic review of literature. Random-effect models were prepared to evaluate the influence of vaccination on recurrent CIN 2+.

RESULTS

Primary end point was CIN2+ in every study. The overall study population included 21,059 patients (3,939 vaccinations vs. 17,150 controls). The results showed a significant risk reduction for the development of new high-grade intraepithelial lesions after HPV vaccination (relative risk (RR) 0.41; 95% CI [0.27; 0.64]), independent from HPV type. Due to the heterogeneous study population multiple sub analyses regarding HPV type, age of patients, time of vaccination and follow-up were performed. Age-dependent analysis showed no differences between women under 25 years (RR 0.47 (95%-CI [0.28; 0.80]) and women of higher age (RR 0.52 (95%-CI [0.41; 0.65]). Results for HPV 16/18 positive CIN2+ showed a RR of 0.37 (95% CI [0.17; 0.80]). Overall, the number of women that would have to be vaccinated before or after conization to prevent one case of recurrent CIN 2+ (NNV) is 45.5.

CONCLUSION

Meta-analysis showed a significant risk reduction of developing recurrent cervical intraepithelial neoplasia after surgical excision and HPV vaccination compared to surgical excision only.

Psychological distress in cervical cancer screening: results from a German online survey

Purpose

The PODCAD study aimed at assessing the degree of psychological stress that women experience due to notification of an abnormal Papanicolaou (Pap) smear finding or a positive human papillomavirus (HPV) test result.

Methods

We designed a survey to address the question of psychological burden due to abnormal Pap smear results and/or positive HPV tests. In this online campaign approach, we aimed to reach > 2000 women all over Germany irrespective of kind and number of abnormal screening findings. We asked for different kinds of anxiety, distress and uncertainty regarding both, Pap and HPV status.

Results

A total of 3753 women completed the survey at least partially, and almost 2300 fully completed the survey. Of these, more than 50% were affected already since more than 1 year, and almost half of them had experienced at least three Pap smears in follow-up examinations. Almost 70% of the women were afraid of developing cancer. Intriguingly, almost half of the women with abnormal findings were not aware of their stage of the Pap smear. Furthermore, almost 30% of the women displayed signs of a post-traumatic stress disorder.

Conclusion

Abnormal results in cervical cancer screening have an impact on patients’ psychology, irrespective of the knowledge and severity of the findings. Better information concerning risks and benefits of cervical cancer screening and about the meaning of the outcome of its procedures are required to decrease this anxiety.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05661-9) contains supplementary material, which is available to authorized users.

Trans-Mucosal Efficacy of Non-Thermal Plasma Treatment on Cervical Cancer Tissue and Human Cervix Uteri by a Next Generation Electrosurgical Argon Plasma Device

Non-invasive physical plasma (NIPP) generated by non-thermally operated electrosurgical argon plasma sources is a promising treatment for local chronic inflammatory, precancerous and cancerous diseases. NIPP-enabling plasma sources are highly available and medically approved. The purpose of this study is the investigation of the effects of non-thermal NIPP on cancer cell proliferation, viability and apoptosis and the identification of the underlying biochemical and molecular modes of action. For this, cervical cancer (CC) single cells and healthy human cervical tissue were analyzed by cell counting, caspase activity assays, microscopic and flow-cytometric viability measurements and molecular tissue characterization using Raman imaging. NIPP treatment caused an immediate and persisting decrease in CC cell growth and cell viability associated with significant plasma-dependent effects on lipid structures. These effects could also be identified in primary cells from healthy cervical tissue and could be traced into the basal cell layer of superficially NIPP-treated cervical mucosa. This study shows that NIPP treatment with non-thermally operated electrosurgical argon plasma devices is a promising method for the treatment of human mucosa, inducing specific molecular changes in cells.

Correlation between referral cytology and in-house colposcopy-guided cytology for detecting early cervical neoplasia

PURPOSE

The current cervical cancer screening program in Germany recommends that the results showing suspected HPV infection should be further examined in specialized colposcopy units. This study aimed to correlate externally documented Pap smear results with in-house colposcopy-guided Pap cytology results and compare colposcopy-guided biopsy and postoperative histopathology results.

METHODS

Clinical data were analyzed from 3627 examinations in 2844 patients who visited a university certified dysplasia unit from 2014 to 2017; 2212 patients underwent complete assessments, including Pap smear, colposcopy, HPV testing, colposcopy-guided biopsy, and/or surgery. The results were analyzed descriptively.

RESULTS

External and in-house Pap results were consistent in 1054 ofthe 2212 patients (47.65%). Referral cytology showed a higher grade than in-house in 456 (20.61%) and a lower grade in 702 (31.74%). Using the histopathological findings as the gold standard, overdiagnosis in the referral cytology was noted in 180 patients (13.19%), underdiagnosis in 263 (19.27%), and concordant findings in 922 (67.55%). For in-house cytology, overdiagnosis was found in 133 patients (10.74%), underdiagnosis in 192 (15.51%), and accurate diagnosis with congruent cytology and histopathology findings in 913 (73.75%).

CONCLUSIONS

The rate of detection of cervical abnormalities differs significantly depending on whether the examination is performed routinely or in specialized units. Colposcopy-guided Pap smears correlate significantly better with histology than referral cytology results without colposcopic guidance. More severe lesions were also detected more accurately.