1
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Armstrong GM, Ragupathy K. Test of cure and beyond: superiority of thermal ablation over LLETZ in the treatment of high-grade CIN. Arch Gynecol Obstet 2022; 306:1815-1820. [PMID: 35107616 PMCID: PMC9519675 DOI: 10.1007/s00404-022-06409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
Purpose Among the treatment modalities for high-grade cervical intraepithelial neoplasia (CIN), large-loop excision of the transformation zone (LLETZ) is the commonest offered in the UK, whereas thermal ablation (TA) has not been common in several decades, despite several notable advantages. TA and LLETZ are both routinely undertaken in our colposcopy unit, and extensive follow-up data have been used to interrogate outcomes between the two modalities and determine whether one modality may be preferred over the other. Methods Up to 8 years of follow-up data (cytology and histology) were collected for patients who have undergone LLETZ or TA and failed post-treatment test of cure (ToC). These data were analysed and used to plot Kaplan–Meier survival curves, in order to compare outcomes: negative cytology, dyskaryosis, low- and high-grade CIN and invasive squamous cell carcinoma. Results i) Very few women treated with TA developed recurrent high-grade CIN in the follow-up period; (ii) LLETZ-treated women had a significantly higher rate of recurrence than those treated by TA; (iii) women who failed both virology and cytology components of post-treatment ToC had higher recurrence than those who failed only one, and the rate of recurrence was highest in those treated by LLETZ (> 65%). Conclusion TA is an effective treatment of high-grade CIN, with a high chance of achieving double-negative ToC and low recurrence relative to LLETZ. We recommend the wider adoption of TA, so that young women of reproductive age have a choice of treatment with no reported adverse effects on pregnancy outcomes.
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Affiliation(s)
| | - K Ragupathy
- Obstetrics and Gynaecology Department, NHS Tayside, Ninewells Hospital, Dundee, UK
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2
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Soler M, Masch R, Saidu R, Cremer M. Thermal Ablation Treatment for Cervical Precancer (Cervical Intraepithelial Neoplasia Grade 2 or Higher [CIN2+]). Methods Mol Biol 2022; 2394:867-882. [PMID: 35094363 DOI: 10.1007/978-1-0716-1811-0_46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cervical cancer is a leading cause of mortality for women in low- and middle-income countries (LMICs). Invasive disease can be prevented through the treatment of high-grade cervical precancer lesions. Types of treatment for cervical precancer include excisional procedures that surgically remove the affected tissue and ablation treatments which utilize extreme temperatures to destroy precancerous cells. Excision is the first-line treatment in higher income countries, but requires specialized training and equipment that make it unsuitable for low-income settings. The most common treatment globally is cryotherapy, which utilizes cryogenic gas to freeze the area. However, the need for gas presents significant procurement and logistical challenges. The World Health Organization (WHO) has recently endorsed the use of thermal ablation, a method that utilizes heat to destroy precancerous tissue. This review describes three existing thermal ablation devices and protocols for their use, including step-by-step instruction guides to perform a successful treatment with each device and observations specific to each machine.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
- Basic Health International, Pittsburgh, PA, USA.
| | | | - Rakiya Saidu
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, Pittsburgh, PA, USA
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3
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Chinula L, Topazian HM, Mapanje C, Varela A, Chapola J, Limarzi L, Stanley C, Hosseinipour M, Gopal S, Tang JH. Uptake and safety of community-based "screen-and-treat" with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi. Int J Cancer 2021; 149:371-377. [PMID: 33687746 DOI: 10.1002/ijc.33549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 01/27/2023]
Abstract
Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy. However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a handheld thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in nonclinic community settings to nonpregnant women aged 25 to 49 years without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed up women at Weeks 6 and 12, with repeat biopsy at Week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n = 30) of women had a positive VIA, of whom 93% (n = 28) underwent same-day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3 and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies that minimize false-positive results are urgently needed in Malawi.
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Affiliation(s)
- Lameck Chinula
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Obstetrics and Gynecology, University of Malawi, College of Medicine, Malawi
| | - Hillary M Topazian
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Clement Mapanje
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Amanda Varela
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - John Chapola
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Laura Limarzi
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Christopher Stanley
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,School of Public Health, Witwatersrand University, Johannesburg, South Africa
| | - Mina Hosseinipour
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Satish Gopal
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer H Tang
- Department of Obstetrics & Gynecology, Division of Global Women's Health, University of North Carolina Project-Malawi, Lilongwe, Malawi.,Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Obstetrics and Gynecology, University of Malawi, College of Medicine, Malawi
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4
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Cubie HA, Campbell C. Cervical cancer screening - The challenges of complete pathways of care in low-income countries: Focus on Malawi. ACTA ACUST UNITED AC 2020; 16:1745506520914804. [PMID: 32364058 PMCID: PMC7225784 DOI: 10.1177/1745506520914804] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cervical cancer is the fourth most common cancer among women globally, with approximately 580,000 new diagnoses in 2018. Approximately, 90% of deaths from this disease occur in low- and middle-income countries, especially in areas of high HIV prevalence, and largely due to limited prevention and screening opportunities and scarce treatment options. In this overview, we describe the opportunities and challenges faced in many low- and middle-income countries in delivery of cervical cancer detection, treatment and complete pathways of care. In particular, drawing on our experience and that of colleagues, we describe cervical screening and pathways of care provision in Malawi, as a case study of a low-resource country with high incidence and mortality rates of cervical cancer. Screening methods such as cytology – although widely used in high-income countries – have limited relevance in many low-resource settings. The World Health Organization recommends screening using human papillomavirus testing wherever possible; however, although human papillomavirus primary testing is more sensitive and detects precancers and cancers earlier than cytology, there are currently costs, infrastructure considerations and specificity issues that limit its use in low- and middle-income countries. The World Health Organization accepts the alternative screening approach of visual inspection with acetic acid as part of ‘screen and treat’ programmes as a simple and inexpensive test that can be undertaken by trained health workers and hence give wider screening coverage; however, subjectivity and variability in interpretation of findings between providers raise issues of false positives and overtreatment. Cryotherapy using either nitrous oxide or carbon dioxide is an established treatment for precancerous lesions within ‘screen and treat’ programmes; more recently, thermal ablation has been recognized as suitable to low-resource settings due to lightweight equipment, short treatment times, and hand-held battery-operated and solar-powered models. For larger lesions and cancers, complete clinical pathways (including loop excision, surgery, radiotherapy, chemotherapy and palliative care) are required for optimal care of women. However, provision of each of these components of cancer control is often limited due to limited infrastructure and lack of trained personnel. Hence, global initiatives to reduce cervical mortality need to adopt a holistic approach to health systems strengthening.
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Affiliation(s)
- Heather A Cubie
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Christine Campbell
- Global Health Academy and Usher Institute, The University of Edinburgh, Edinburgh, UK
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5
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de Fouw M, Oosting RM, Rutgrink A, Dekkers OM, Peters AAW, Beltman JJ. A systematic review and meta-analysis of thermal coagulation compared with cryotherapy to treat precancerous cervical lesions in low- and middle-income countries. Int J Gynaecol Obstet 2019; 147:4-18. [PMID: 31273785 DOI: 10.1002/ijgo.12904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 05/09/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy. OBJECTIVES Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs. SEARCH STRATEGY Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010. SELECTION CRITERIA Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up. DATA COLLECTION AND ANALYSIS Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region. MAIN RESULTS Pooled cure proportions for cryotherapy and thermal coagulation, respectively, were 93.8% (95% CI, 88.5-97.7) and 91.4% (95% CI, 84.9-96.4) for CIN 1; 82.6% (95% CI, 77.4-87.3) and 91.6% (95% CI, 88.2-94.5) for CIN 2-3; and 92.8% (95% CI, 85.6-97.7) and 90.1% (95% CI, 87.0-92.8) for VIA-positive lesions. For thermal coagulation of CIN 2-3 lesions in LMICs 82.4% (95% CI, 75.4-88.6). CONCLUSIONS Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs.
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Affiliation(s)
- Marlieke de Fouw
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Roos Marieke Oosting
- Department of BioMechanical Engineering, Delft University of Technology, Delft, Netherlands
| | - Amy Rutgrink
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Olaf Matthijs Dekkers
- Department of Clinical Epidemiology and Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jogchum Jan Beltman
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
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6
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Randall TC, Sauvaget C, Muwonge R, Trimble EL, Jeronimo J. Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions. Prev Med 2019; 118:81-91. [PMID: 30342109 DOI: 10.1016/j.ypmed.2018.10.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022]
Abstract
Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.
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Affiliation(s)
- Thomas C Randall
- Gynecologic Oncology, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Edward L Trimble
- Global HPV and Cervical Cancer Research and Control, National Cancer Institute, Rockville, MD, USA
| | - Jose Jeronimo
- Global Coalition Against Cervical Cancer, Seattle, WA, USA
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7
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Cremer ML, Conzuelo-Rodriguez G, Cherniak W, Randall T. Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions. J Glob Oncol 2018; 4:1-10. [PMID: 30372399 PMCID: PMC7010451 DOI: 10.1200/jgo.18.00093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.
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Affiliation(s)
- Miriam L. Cremer
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Gabriel Conzuelo-Rodriguez
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - William Cherniak
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Thomas Randall
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
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8
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Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study. Arch Gynecol Obstet 2018; 297:1015-1025. [PMID: 29404740 DOI: 10.1007/s00404-018-4704-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTS We identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, Birmingham Women's Hospital, The University of Birmingham, Academic Unit, Mindelsohn Way, Edgbaston, Birmingham, B15 2TG, UK
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
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9
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Castle PE, Murokora D, Perez C, Alvarez M, Quek SC, Campbell C. Treatment of cervical intraepithelial lesions. Int J Gynaecol Obstet 2017; 138 Suppl 1:20-25. [PMID: 28691333 DOI: 10.1002/ijgo.12191] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Precancerous cervical lesions precede the development of invasive cervical cancer by 10-20 years, making cervical cancer preventable if these lesions are detected and effectively treated. Treatment has evolved in the last few decades and now includes ablative options that can be performed in lower-resource settings where surgical excision is not feasible or routinely available. Gas-based cryotherapy, which freezes cervical tissue to induce localized necrosis, is the most commonly used ablative treatment. However, its implementation in low-resource settings is difficult because the refrigerant gas can be difficult to procure and transport, and is expensive. New cryotherapy devices that do not require an external supply of gas appear promising. Thermal coagulation, which burns cervical tissue to induce necrosis, has become more widely available in the last few years owing to its portability and the feasibility of using battery-powered devices. These two ablative treatments successfully eradicate 75%-85% of high-grade cervical lesions and have minor adverse effects.
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Affiliation(s)
| | - Dan Murokora
- Uganda Women's Health Initiative, Kampala, Uganda
| | | | - Manuel Alvarez
- Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
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10
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Kunckler M, Schumacher F, Kenfack B, Catarino R, Viviano M, Tincho E, Tebeu PM, Temogne L, Vassilakos P, Petignat P. Cervical cancer screening in a low-resource setting: a pilot study on an HPV-based screen-and-treat approach. Cancer Med 2017; 6:1752-1761. [PMID: 28580596 PMCID: PMC5504339 DOI: 10.1002/cam4.1089] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/30/2017] [Accepted: 03/31/2017] [Indexed: 01/24/2023] Open
Abstract
Cervical cancer (CC) is the leading cause of cancer‐related death among women in sub‐Saharan Africa, primarily because of limited access to effective screening and preventive treatment. Our aim was to assess the feasibility of a human papillomavirus (HPV)‐based CC screen‐and‐treat approach in a low‐resource context. We recruited 1012 women aged 30–49 years through a CC screening campaign conducted in the District Hospital of Dschang, Cameroon. Participants performed HPV self‐sampling, which was tested for high‐risk HPV (HR‐HPV) DNA using the point‐of‐care Xpert HPV assay. All HPV‐positive women were invited for visual inspection with acetic acid and Lugol's iodine (VIA/VILI) to exclude CC or enable triage. A cervical sample for histological analysis was also collected. Women positive for HPV 16/18/45 and for other HR‐HPV with pathological VIA/VILI were selected to undergo treatment with thermocoagulation. The HPV prevalence in the study population was 18.5% (n = 187); of these cases, 20 (10.6%), 42 (22.3%) and 140 (74.9%) were positive for HPV16, HPV18/45 and other HR‐HPV types, respectively. Overall, 107/185 (57.8%) VIA/VILI examinations were classified as pathological and 78 (42.2%) as normal. Women positive for HPV16/18/45 were 4.2 times more likely to harbor cervical intraepithelial neoplasia grade 2 or worse (CIN2+) than those with other HPV types. The specificity of HPV 16/18/45 genotypes for detection of high‐grade lesions among HR‐HPV positive women was higher than that of VIA/VILI in all age groups. The sensitivity and specificity of VIA/VILI in detecting CIN2+ among HPV positive women were 80% and 44%, respectively. Overall, 110/121 screen‐positive women (90.9%) were eligible for, and were treated with, thermocoagulation. An HPV‐based screen‐and‐treat approach is feasible in a low‐resource context and may contribute to improving the effectiveness of CC prevention programs. Immediate thermocoagulation treatment for women who are HPV16‐ and/or HPV18/45‐positive is a practical approach for the treatment of CIN2+. The combination of HPV‐testing and VIA/VILI for CC screening might reduce overtreatment.
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Affiliation(s)
- Margot Kunckler
- Gynecology Division, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Fanny Schumacher
- Gynecology Division, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Rosa Catarino
- Gynecology Division, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Manuela Viviano
- Gynecology Division, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Eveline Tincho
- Faculty of Medicine and Biomedical Sciences, Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon
| | - Pierre-Marie Tebeu
- Faculty of Medicine and Biomedical Sciences, Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon
| | - Liliane Temogne
- Faculty of Medicine and Biomedical Sciences, Centre Hospitalier Universitaire (CHUY), Yaoundé, Cameroon
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Department of Obstetrics and Gynecology, University Hospitals of Geneva, Geneva, Switzerland
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11
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Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment. Geburtshilfe Frauenheilkd 2017; 77:284-289. [PMID: 28392582 DOI: 10.1055/s-0042-119993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7 %) cases of CIN2 and 142 (35.3 %) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1 % were nulliparous and 36.6 % were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7 % and 57.1 %. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6 %, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95 % CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.
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Affiliation(s)
- D Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - M Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - W Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
| | - J Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, United Kingdom
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Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study. Arch Gynecol Obstet 2017; 295:979-986. [PMID: 28229232 DOI: 10.1007/s00404-017-4306-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 01/25/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies. METHODS This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment. RESULTS We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months. CONCLUSION We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Princess Royal Hospital, Apley Castle, Grainger Drive, Telford, TF16TF, UK
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13
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Viviano M, Kenfack B, Catarino R, Tincho E, Temogne L, Benski AC, Tebeu PM, Meyer-Hamme U, Vassilakos P, Petignat P. Feasibility of thermocoagulation in a screen-and-treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa. BMC WOMENS HEALTH 2017; 17:2. [PMID: 28061842 PMCID: PMC5219781 DOI: 10.1186/s12905-016-0355-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/08/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND The use of thermocoagulation for the treatment of cervical precancerous lesions has recently generated a great deal of interest. Our aim was to determine the feasibility of this outpatient procedure in the context of a cervical cancer (CC) screen-and-treat campaign in sub-Saharan Africa. METHODS Between July and December 2015, women living in the area of Dschang (Cameroon) aged between 30 and 49 years, were enrolled in a CC screening study. HPV self-sampling was performed as a primary screening test and women who were either "HPV 16/18/45-positive" or "positive to other HPV types and to VIA" were considered screen-positive, thus requiring further management. The primary outcome was the percentage of screen-positive patients who met the criteria to undergo thermocoagulation. The secondary outcome was the assessment of the procedure's side effects immediately after treatment and at the 1-month follow-up visit. RESULTS A total of 1012 women were recruited in the study period. Among 121 screen-positive women, 110 of them (90.9%) were eligible to be treated with thermocoagulation. No patients discontinued treatment because of pain or other side effects. The mean ± SD (Standard Deviation) score measured on the 10-point Visual Analogue Scale (VAS) was 3.0 ± 1.6. Women having less than 2 children were more likely to report a higher pain score than those with more than two (4.2 ± 2.0 versus 2.9 ± 1.5, respectively; p value = 0.016). A total of 109/110 (99.1%) patients came to the 1-month follow-up visit. Vaginal discharge was reported in 108/109 (99.1%) patients throughout the month following treatment. Three patients (2.8%) developed vaginal infection requiring local antibiotics. No hospitalizations were required. CONCLUSION The majority of screen-positive women met the criteria and could be treated by thermocoagulation. The procedure was associated to minor side effects and is overall feasible in the context of a CC screen-and-treat campaign in sub-Saharan Africa. TRIAL REGISTRATION The trial was retrospectively registered on November 11, 2015 with the identifier: ISRCTN99459678 .
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Affiliation(s)
- Manuela Viviano
- Division of Gynaecology, Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland. .,Division of Gynecology, Geneva University Hospitals, Boulevard de la Cluse 30, 1205, Geneva, Switzerland.
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | - Rosa Catarino
- Division of Gynaecology, Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Eveline Tincho
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | - Liliane Temogne
- Department of Biomedical Sciences, University of Dschang, Dschang, Cameroon
| | - Anne-Caroline Benski
- Division of Gynaecology, Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.,Saint Damien Medical Centre, Ambanja, Madagascar
| | - Pierre-Marie Tebeu
- Department of Gynecology and Obstetrics, University Centre Hospital, Yaoundé, Cameroon
| | - Ulrike Meyer-Hamme
- Division of Gynaecology, Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Division of Gynaecology, Department of Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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McCarthy CM, Ramphul M, Madden M, Hickey K. The use and success of cold coagulation for the treatment of high grade squamous cervical intra-epithelial neoplasia: a retrospective review. Eur J Obstet Gynecol Reprod Biol 2016; 203:225-8. [PMID: 27343739 DOI: 10.1016/j.ejogrb.2016.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/26/2016] [Accepted: 05/13/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Cold coagulation is recognised as a viable, cost-effective and successful treatment for cervical intraepithelial neoplasia (CIN), being used less frequently than excisional treatments for high grade lesions. We set out to demonstrate successful long term follow-up of patient with high grade CIN treated with cold coagulation. STUDY DESIGN We conducted a retrospective review over a one-year period of women with biopsy-proven CIN 2 and 3 who were treated with cold coagulation to the cervix, attending the colposcopy service of a large tertiary referral hospital. We examined follow-up cervical smear data for three years post treatment of low and high grade CIN, evaluated the success of treatment and re-treatment rates. RESULTS 93 patients were included in our study, with 39 (41.9%) having CIN 1 and 54 (58.1%) diagnosed with CIN 2 or 3. Follow-up smears revealed low levels of recurrent high grade changes in both groups, with 31 (79.5%) of our CIN 1 group having a negative smear one year following treatment with cold coagulation, compared to 44 (81.1%) of patients with CIN 2 and 3. Successful primary treatment (i.e. no requirement for further treatment after 3 year follow-up) occurred in 33 (84.6%) of the CIN 1 group, and 42 (77.7%) of the CIN 2/3 group, demonstrating no statistical significance between re-treatment rates between both groups. CONCLUSIONS This study demonstrates the effectiveness of cold coagulation for the treatment of high grade cervical intraepithelial neoplasia. High success rates, and low re-treatment rates confirm that this is an acceptable primary treatment for CIN 2 and 3.
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Affiliation(s)
- C M McCarthy
- Department of Gynaecology, University Hospital Limerick, Limerick, Ireland.
| | - M Ramphul
- Department of Gynaecology, University Hospital Limerick, Limerick, Ireland
| | - M Madden
- Department of Gynaecology, University Hospital Limerick, Limerick, Ireland
| | - K Hickey
- Department of Gynaecology, University Hospital Limerick, Limerick, Ireland
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Campbell C, Kafwafwa S, Brown H, Walker G, Madetsa B, Deeny M, Kabota B, Morton D, Ter Haar R, Grant L, Cubie HA. Use of thermo-coagulation as an alternative treatment modality in a 'screen-and-treat' programme of cervical screening in rural Malawi. Int J Cancer 2016; 139:908-15. [PMID: 27006131 PMCID: PMC5084797 DOI: 10.1002/ijc.30101] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/01/2016] [Accepted: 02/19/2016] [Indexed: 12/22/2022]
Abstract
The incidence of cervical cancer in Malawi is the highest in the world and projected to increase in the absence of interventions. Although government policy supports screening using visual inspection with acetic acid (VIA), screening provision is limited due to lack of infrastructure, trained personnel, and the cost and availability of gas for cryotherapy. Recently, thermo‐coagulation has been acknowledged as a safe and acceptable procedure suitable for low‐resource settings. We introduced thermo‐coagulation for treatment of VIA‐positive lesions as an alternative to cryotherapy within a cervical screening service based on VIA, coupled with appropriate, sustainable pathways of care for women with high‐grade lesions and cancers. Detailed planning was undertaken for VIA clinics, and approvals were obtained from the Ministry of Health, Regional and Village Chiefs. Educational resources were developed. Thermo‐coagulators were introduced into hospital and health centre settings, with theoretical and practical training in safe use and maintenance of equipment. A total of 7,088 previously unscreened women attended VIA clinics between October 2013 and March 2015. Screening clinics were held daily in the hospital and weekly in the health centres. Overall, VIA positivity was 6.1%. Almost 90% received same day treatment in the hospital setting, and 3‐ to 6‐month cure rates of more than 90% are observed. Thermo‐coagulation proved feasible and acceptable in this setting. Effective implementation requires comprehensive training and provider support, ongoing competency assessment, quality assurance and improvement audit. Thermo‐coagulation offers an effective alternative to cryotherapy and encouraged VIA screening of many more women. What's new? Malawi has the highest incidence rates for cervical cancer worldwide, and a “screen‐and‐treat” program is in place to identify and treat precancerous lesions. Conventional cryotherapy is challenging as gas supply is inconsistent, cylinders are difficult to transport and running costs are high. Here, the authors introduce thermo‐coagulation as a treatment alternative, which proved feasible and acceptable in this resource‐poor setting and could increase the number of women receiving timely treatment for precancerous lesions in low‐ and middle‐income countries.
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Affiliation(s)
- Christine Campbell
- Usher Institute for Population Health Sciences and Informatics, Teviot Place, University of Edinburgh, EH8 9AG, United Kingdom
| | | | - Hilary Brown
- Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom
| | - Graeme Walker
- Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, United Kingdom
| | | | - Miriam Deeny
- Department of Gynaecology, Stobhill Hospital, Glasgow, G21 3UW, United Kingdom
| | | | | | | | - Liz Grant
- Global Health Academy, University of Edinburgh, 1 George Square, Edinburgh, EH8 9JZ, United Kingdom
| | - Heather A Cubie
- Global Health Academy, University of Edinburgh, 1 George Square, Edinburgh, EH8 9JZ, United Kingdom
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Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Risk factors for treatment failure following cold coagulation cervical treatment for CIN pathology: a cohort-based study. Arch Gynecol Obstet 2015; 292:1329-37. [DOI: 10.1007/s00404-015-3761-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/13/2015] [Indexed: 01/08/2023]
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