Prospective cohort study examining cervical cancer screening methods in HIV-positive and HIV-negative Cambodian Women: a comparison of human papilloma virus testing, visualization with acetic acid and digital colposcopy

Evolution of Pathological Techniques for the Screening of Cervical Cancer: A Comprehensive Review

The evolutionary journey of cervical cancer screening has been a major medical success story, considering the substantial role it has played in dwindling the disease burden. Through sustained collaborative efforts within the medical community, significant advances have been made from the humble yet path-breaking conventional Pap smear to the current automated screening systems and human papillomavirus (HPV) molecular testing. With the integration of artificial intelligence into screening techniques, we are currently at the precipice of circumventing the pitfalls of manual cytology readings and improving the efficiency of the screening systems by a significant margin. Despite the technological milestones traversed, the high logistics and operational cost, besides the technical know-how of operating the automated systems, can pose a major practical challenge in the widespread adoption of these advanced techniques in cervical cancer screening programs. This would suggest the need to adopt strategies that are tailored to the demands and needs of the different settings keeping their limitations in mind. This review aims to take the reader through the entire evolutionary journey of cervical cancer screening programs, highlight the individual merits and demerits of each technique, and discuss the recommendations from the major global guidelines.

Feasibility, accuracy and acceptability of self-sampled human papillomavirus testing using careHPV in Cambodia: a cross-sectional study

OBJECTIVE

Self-sampled human papillomavirus (HPV) testing is a potential option for cervical cancer screening, but research is scarce in Cambodia. We evaluated the feasibility, accuracy, and acceptability of self-sampled HPV testing using careHPV.

METHODS

A cross-sectional study including women aged 20-49 years attending 2 national hospitals in the capital city was conducted. Women underwent both self-sampling and clinician-sampling of specimens, and were then asked to complete an acceptability questionnaire. The paired samples were analyzed for high-risk HPV by careHPV and genotyped by polymerase chain reaction (PCR).

RESULTS

A total of 375 women were eligible for inclusion. Based on PCR, 78.9% were negative for HPV in both self and clinician-samples, 9.9% had a complete HPV type match, and 6.1% had all HPV types in clinician-samples also detected in self-samples. In 5.1%, one or more HPV types identified in the clinician-samples were missed in self-samples. When using careHPV, the overall agreement between the 2 sampling methods was 95.7% (95% confidence interval [CI]=95.8-95.6) with good concordance (κ=0.66, 95% CI=0.56-0.76). Nearly 90% of the women preferred clinician-sampling over self-sampling, citing greater comfort, ease, and speed.

CONCLUSION

Self-sampled HPV testing using careHPV could be an option for cervical cancer screening in Cambodia; however, it requires periodic quality control of handling procedures. In addition, women's health education regarding the accuracy of self-sampled HPV testing and the importance of follow-up in cases of positive results is needed.

Automated Assessment of Digital Images of Uterine Cervix Captured Using Transvaginal Device-A Pilot Study

In low-resource settings, a point-of-care test for cervical cancer screening that can give an immediate result to guide management is urgently needed. A transvaginal digital device, "Smart Scope®" (SS), with an artificial intelligence-enabled auto-image-assessment (SS-AI) feature, was developed. In a single-arm observational study, eligible consenting women underwent a Smart Scope®-aided VIA-VILI test. Images of the cervix were captured using SS and categorized by SS-AI in four groups (green, amber, high-risk amber (HRA), red) based on risk assessment. Green and amber were classified as SS-AI negative while HRA and red were classified as SS-AI positive. The SS-AI-positive women were advised colposcopy and guided biopsy. The cervix images of SS-AI-negative cases were evaluated by an expert colposcopist (SS-M); those suspected of being positive were also recommended colposcopy and guided biopsy. Histopathology was considered a gold standard. Data on 877 SS-AI, 485 colposcopy, and 213 histopathology were available for analysis. The SS-AI showed high sensitivity (90.3%), specificity (75.3%), accuracy (84.04%), and correlation coefficient (0.670, p = 0.0) in comparison with histology at the CINI+ cutoff. In conclusion, the AI-enabled Smart Scope® test is a good alternative to the existing screening tests as it gives a real-time accurate assessment of cervical health and an opportunity for immediate triaging with visual evidence.

Digital cervicography for cervical cancer screening in low-resource settings: A scoping review

Introduction

Digital cervicography (DC) is a method of capturing images for analysis during visual inspection with acetic acid (VIA) for cervical cancer screening. Cervical cancer is the 3rd leading cause of female cancer in the world with approximately 90 % of deaths due to cervical cancer occurring in low and middle income countries (LMICs). The need for cost-effective and sustainable methods for screening is vital in these settings. This scoping review systematically synthesizes published data illustrating the use of DC in screening programs. We aim to understand how digital cervicography is used, implemented, and impacted on programs.

Methods

Search of eight online databases identified 53 studies published between 1993 and 2021. Inclusion of articles were English language, cervical cancer screening program located in an LMIC, and DC as an intervention.

Results

All studies were cross-sectional studies (n = 53), with variation in terminology, uses, and device methods. Devices were grouped as either smartphones (n = 14), commercially available digital cameras (n = 17), or other (EVA®, n = 4; Cerviscope, n = 12; custom device, n = 4; or not specified, n = 2). Nineteen studies found acceptability and feasibility for DC in their screening programs. Various programs using DC found benefits such as task sharing, healthcare worker training, patient education and using images for review from a remote specialist or mentor.

Conclusion

The use of DC in LMICs is beneficial for support of healthcare workers, enhances quality improvement and demonstrates overall acceptability in screening programs. Advancing technologies for human papillomavirus (HPV) testing and cytology are common methods for cervical cancer screening, although are limited in LMICs. This scoping review demonstrates the different methods, uses, and benefit of digital cervicography in cervical cancer screening programs.

Self-Collection Cervical Screening in the Asia-Pacific Region: A Scoping Review of Implementation Evidence

PURPOSE

Although cervical cancer is a disease of inequity, it can be eliminated as a public health problem through vaccination, screening, and treatment. Human papillomavirus vaginal self-collection cervical screening is a high-performance test that can increase reach of screening. This review describes the different contexts and models of care used to pilot or implement self-collection within the Asia-Pacific, measures the extent that implementation outcome measures are reported and, where available, summarizes key implementation findings.

METHODS

A scoping review was conducted by searching five databases of the peer-reviewed literature on June 20, 2022. Two researchers assessed eligibility and extracted data independently to the model of care used and the Conceptual Framework for Implementation Outcomes. A mixed-method consolidation of findings (quantitative: count and frequencies; qualitative: content analysis) was undertaken to narratively report findings.

RESULTS

Fifty-seven articles, comprising 50 unique studies from 11 countries and two special autonomous regions, were included; 82% were conducted in trials. The implementation of self-collection was conducted in low- (2%), lower-middle- (32%), upper-middle- (32%), and high-income (35%) settings, with 10 different delivery models used; 80% delivered through practitioner-supported models with diversity in how samples were processed, and treatment was offered. Acceptability (73%) and appropriateness (64%) measures were most reported, followed by adoption (57%), feasibility (48%), and fidelity (38%). Only 7% of articles reported implementation cost or penetration measures. No articles reported sustainability measures.

CONCLUSION

The literature confirms that self-collection cervical screening has been implemented within the Asia-Pacific region, with evidence demonstrating that it is acceptable and appropriate from the user's perspective. Well-designed, high-quality implementation trials and real-world evaluations of self-collection that report the breadth of implementation outcomes can support the progression toward the elimination of cervical cancer.

Sexual health and quality-of-life concerns of cervical dysplasia treatments: Review

Thorough investigations have defined underlying disease mechanisms, determining effective cervical dysplasia (CD) treatments. Previous work has assessed the effects of different treatments on women’s sexual health. Recently however, several published studies have expanded the scope of findings, revealing the need for an updated examination and integration of knowledge to appropriately contextualize this clinical approach within sexual medicine and women’s healthcare. A review of relevant literature was completed. The findings indicate that treatments for CD may be correlated with sexual issues such as decreased interest and sexual functioning, and decreased QoL including psychosocial elements like anxiety. Methodological variations used to investigate different CD treatment outcomes were observed and should be streamlined to facilitate comparison in future studies. There is a need for additional research into alternative non-surgical CD treatments which could mitigate unintended outcomes, and consideration should be given to accessibility of these treatments across different regions in Canada.

Analysis of Distributions of HPV Infection in Females with Cervical Lesions in the Western District of Beijing Chaoyang Hospital

Objective

To analyze the distribution of human papilloma virus (HPV) infection in women with cervical lesions of different grades and analyze the relationship of high-risk HPV and cervical lesions in order to facilitate targeted prevention.

Methods

The infection status of HPV subtype was statistically analyzed in patients who underwent colposcopy examination from April 2017 to June 2019.

Results

The infection rate of HPV was 81.4% in chronic cervicitis, 82.9% in 1ow-grade squamous intraepithelial lesion (LSIL), 63.7% in HSIL (high-grade squamous intraepithelial lesion), and 50% in cervical squamous cell carcinoma (CSCC). Among the 16 high-risk HPV types, the top six HPV types with the comprehensive infection rates were HPV16 > HPV52 > HPV58 > HPV18 > HPV51 > HPV53 in turn, and the infection rates were 23.3%, 14.8%, 13.3%, 9.8%, 9.2%, and 8.8%, respectively. The infection rates of HPV16 in chronic cervicitis group, LSIL group, and HSIL group were significantly different. There was no significant difference in the injection rates of HPV52, HPV58, and HPV18 among the three groups. HPV infection rates were highest in the 31–40 years old group, followed by the 41–50 years old group.

Conclusion

The distribution of different types of HPV varies in different tissue types, which can be used to develop relevant vaccines to achieve better prevention and treatment of cervical cancer.

Smartphone-Based Visual Inspection with Acetic Acid: An Innovative Tool to Improve Cervical Cancer Screening in Low-Resource Setting

Visual inspection with acetic acid (VIA) is recommended by the World Health Organization for primary cervical cancer screening or triage of human papillomavirus-positive women living in low-resource settings. Nonetheless, traditional VIA with the naked-eye is associated with large variabilities in the detection of pre-cancer and with a lack of quality control. Digital-VIA (D-VIA), using high definition cameras, allows magnification and zooming on transformation zones and suspicious cervical regions, as well as simultaneously compare native and post-VIA images in real-time. We searched MEDLINE and LILACS between January 2015 and November 2021 for relevant studies conducted in low-resource settings using a smartphone device for D-VIA. The aim of this review was to provide an evaluation on available data for smartphone use in low-resource settings in the context of D-VIA-based cervical cancer screenings. The available results to date show that the quality of D-VIA images is satisfactory and enables CIN1/CIN2+ diagnosis, and that a smartphone is a promising tool for cervical cancer screening monitoring and for on- and off-site supervision, and training. The use of artificial intelligence algorithms could soon allow automated and accurate cervical lesion detection.

Cervical cancer prevention and control in women living with human immunodeficiency virus

Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.

Cervical Cancer Prevention in Low- and Middle-Income Countries

Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.

A pilot study of mobile digital colposcopy in Japanese patients with cervical intraepithelial neoplasm

Digital colposcopy built around a smartphone is becoming common, and this has advantages for telemedicine and data sharing by taking advantage of smartphone characteristics. However, digital colposcopy itself is not allowed in clinical practice in Japan. The aim of the present study was to investigate the feasibility of mobile digital colposcopy incorporating a smartphone for management of cervical screening in Japanese patients. Patients who underwent colposcopy at Saitama Medical University International Medical Center between July 2019 and February 2020 were enrolled in the present study. The inclusion criteria were women aged 21-65 years old referred for colposcopy following the Japanese standard of care. Written informed consent was obtained from all patients. A total of 40 patients (52 tests) were included in the study. Following the standard of care, acetic acid was applied to the cervix, which was then visualized using a traditional colposcope, with biopsies collected as necessary. The cervix was then visualized and an imaged was captured using a mobile digital colposcope incorporating a smartphone (EVA System; Mobile ODT). All images were collected before biopsy. Images were stored on a secure cloud portal for subsequent evaluation by the provider who performed the conventional colposcopy, and the diagnoses were compared. The present study was approved by the Institutional Review Board of Saitama Medical University International Medical Center (Hidaka, Japan). The match rates for diagnoses were 75%. The match rates for the actual (from conventional colposcopy) and assumed (from digital colposcopy) biopsy sites were 61, 16 and 23%, based on definitions of the ‘same’, ‘almost the same’ and ‘different’, respectively. The present results indicated that ≥75% cases were equivalent in digital colposcopy and conventional colposcopy. This suggests that digital colposcopy may not be inferior to conventional colposcopy.

Comparative Study of Smart Scope® Visual Screening Test with Naked Eye Visual Screening and Pap Test

Background:

Cervical cancer is a major contributor to mortality and morbidity in women. Naked eye visual screening (NE test) and Pap test are commonly used for cervical cancer screening. Both tests have inherent limitations like low sensitivity (Pap test) and subjectivity in interpretation, lack of permanent record and overestimation (NE test). Here, Smart Scope^® visual screening test (SS test) was compared with NE and Pap tests. Smart Scope^® is a small, hand-held device that captures cervical images attached to a tablet to store data.

Objective:

To compare SS test with Pap and NE tests.

Study Design:

This prospective observational study was conducted at a tertiary care hospital in India, over 16 months. A total of 509 women in the age group of 25 to 65 years were included in the study as per the inclusion criteria. All the participants underwent Pap test, NE test and SS test. Screen positives on any one test were advised colposcopy and biopsy.

Results:

Out of 154 screen-positive women, 49 visited for follow-up colposcopy-guided biopsy. Nine incidental biopsies of screen-negative women were included in the data. Thus, statistical analysis was carried out based on 58 available histopathology results. Out of 58 biopsies, 8 were normal, 30 were benign lesions, 18 were precancerous and 2 were cancerous lesions. SS test was found to have a sensitivity and NPV of 100% each, PPV of 45.4% and a specificity of 36.8%. Sensitivity and specificity of NE test was 90% and 39.5% respectively, PPV was 43.9% and NPV was 88.2%. Pap smear had a sensitivity of 25% and specificity of 84.2%, PPV of 45.5% and NPV of 68.08%.

Conclusion:

SS test has great potential to be a primary screening test in low-resource settings due to its better sensitivity and NPV as compared to NE and Pap tests.

The early detection of cervical cancer. The current and changing landscape of cervical disease detection

Cervical cancer prevention has undergone dramatic changes over the past decade. With the introduction of human papillomavirus (HPV) vaccination, some countries have seen a dramatic decline in HPV-mediated cervical disease. However, widespread implementation has been limited by economic considerations and the varying healthcare priorities of different countries, as well as by vaccine availability and, in some instances, vaccine hesitancy amongst the population/government. In this environment, it is clear that cervical screening will retain a critical role in the prevention of cervical cancer and will in due course need to adapt to the changing incidence of HPV-associated neoplasia. Cervical screening has, for many years, been performed using Papanicolaou staining of cytology samples. As our understanding of the role of HPV in cervical cancer progression has advanced, and with the availability of sensitive detection systems, cervical screening now incorporates HPV testing. Although such tests improve disease detection, they are not specific, and cannot discriminate high-grade from low-grade disease. This has necessitated the development of effective triage approaches to stratify HPV-positive women according to their risk of cancer progression. Although cytology triage remains the mainstay of screening, novel strategies under evaluation include DNA methylation, biomarker detection and the incorporation of artificial intelligence systems to detect cervical abnormalities. These tests, which can be partially anchored in a molecular understanding of HPV pathogenesis, will enhance the sensitivity of disease detection and improve patient outcomes. This review will provide insight on these innovative methodologies while explaining their scientific basis drawing from our understanding of HPV tumour biology.

Assessing the feasibility of a rapid, high-volume cervical cancer screening programme using HPV self-sampling and digital colposcopy in rural regions of Yunnan, China

OBJECTIVE

Implementation of a novel, rapid, high-volume, see-and-treat cervical cancer screening programme using self-swab human papillomavirus (HPV) testing and digital colposcopy in underserved regions of Yunnan China.

DESIGN

480-980 women per day self-swabbed for high-risk HPV (hrHPV+). Four careHPV machines (Qiagen) were run simultaneously to test the specimens. All hrHPV+ patients were contacted the same day and digital colposcopy was performed with the enhanced visual assessment system (MobileODT). Digital images were obtained, and all suspected lesions were biopsied and then treated.

SETTING

Rural and underserved areas of the Yunnan province, Kunming municipality.

PARTICIPANTS

3600 women, mean age 50.2 years, who had never been screened for cervical cancer. The women were of the Yi, Hui, Dai and Han ethnicities.

INTERVENTIONS

Cryotherapy was performed on all lesions suspicious for cervical intraepithelial neoplasia (CIN) 1 and loop electrosurgical excision procedure was performed on all lesions suspicious for ≥CIN2. Endocervical curettage was performed if the transformation zone was not fully visualised.

RESULTS

216 women (6%) were hrHPV+. 168 underwent same-day colposcopy (23 CIN1, 17≥CIN2). Digital colposcopy was able to identify 15 of 16 (93.8%)≥CIN2 lesions.

CONCLUSIONS

This study illustrates a high-volume, rapid and practical strategy that can be used to screen and treat an ethnically diverse group of Chinese women. First, HPV self-sampling allows large numbers of women to be screened rapidly and relatively inexpensively. Only hrHPV+ women will then require further evaluation. Digital colposcopy is then performed on hrHPV+ women with a portable digital colposcope. The high-resolution images obtained can facilitate appropriate same-day treatment as they are able to accurately distinguish between CIN1 and ≥CIN2 lesions.

Cervical Cancer Screening: Past, Present, and Future

INTRODUCTION

Cervical cancer is the leading cause of cancer deaths in women in the developing world. New technologies have been developed to allow for more rapid, cost-effective, and sensitive cervical cancer screening and treatment.

AIM

The aim of this study was to describe methods for detection and treatment of human papillomavirus (HPV), cervical dysplasia (CD), and cervical cancer. New technologies and updated screening strategies will be emphasized.

METHODS

A literature search was conducted using PubMed to identify publications relevant to the subject.

MAIN OUTCOME MEASURE

Sensitivity and cost-effectiveness of new cervical cancer screening methods were the main outcome measures.

RESULTS

HPV and cervical cancer have a significant global impact. Research and innovations related to detection and treatment are key in reducing their burden worldwide.

CONCLUSION

Screening a woman for HPV and CD can dramatically decrease her risk of dying from cervical cancer. New, rapid, low-cost, HPV testing can allow for high-volume screening for the approximately 1.5 billion women who have never been screened. HPV screening can then be combined with high resolution digital colposcopy to detect CD. In the near future, these colposcopic images will be interpreted by artificial intelligence software. Detected lesions can then be treated easily and effectively with thermocoagulation. This see-and-treat model is a sensitive, efficient, and low-cost vision for the future. Bedell SL, Goldstein LS, Goldstein AR, et al. Cervical Cancer Screening: Past, Present, and Future. Sex Med Rev 2020;8:28-37.

The use of molecular markers for cervical screening of women living with HIV in South Africa

Supplemental Digital Content is available in the text

To determine the performance of molecular screening strategies for detection of cervical intraepithelial neoplasia grade 3 or worse (CIN3+) in comparison with cytology screening in women living with HIV.

Advances in technologies for cervical cancer detection in low-resource settings

Introduction: Cervical cancer mortality rates remain high in low- and middle-income countries (LMICs) and other medically underserved areas due to challenges with implementation and sustainability of routine screening, accurate diagnosis, and early treatment of preinvasive lesions. Areas covered: In this review, we first discuss the standard of care for cervical cancer screening and diagnosis in high- and low-resource settings, biomarkers that correlate to cervical precancer and cancer, and needs for new tests. We review technologies for screening and diagnosis with a focus on tests that are already in use in LMICs or have the potential to be adapted for use in LMICs. Finally, we provide perspectives on the next five years of technology development for improved cervical cancer screening and diagnosis in LMICs. Expert opinion: Innovation toward improved molecular and imaging tests is needed to enable effective, affordable see-and-treat approaches to detect and treat cervical precancer in a single visit. Current molecular tests remain too complex and/or costly for widespread use. Especially with imaging tests, decision support may improve performance of new technologies.