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Bertelsen VM, Tranberg M, Petersen LK, Booth B, Bor P. Improving diagnostic of cervical dysplasia among postmenopausal women aged ≥50 years using local vaginal oestrogen treatment prior to colposcopy: study protocol for a multicentre randomised controlled trial (the IDEAL study). BMJ Open 2024; 14:e082833. [PMID: 38910002 PMCID: PMC11328618 DOI: 10.1136/bmjopen-2023-082833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
INTRODUCTION Colposcopy is the most important diagnostic tool to detect cervical precancerous lesions and thereby prevention of cervical cancer. Due to age-dependent changes of the cervix, colposcopy is challenging in postmenopausal women, as the majority will have a non-visible transformation zone, resulting in increased risk of missing disease, a diagnostic cone biopsy and prolonged follow-up with repeated colposcopies. This study will be among the first to investigate, if treatment with vaginal oestrogen prior to colposcopy will improve the colposcopy performance, to ensure accurate and timely diagnosis of precancerous cervical lesions among postmenopausal women. METHODS AND ANALYSIS A randomised blinded controlled multicentre study. Enrolment will be performed at gynaecology departments in Central Denmark Region and Region of Southern Denmark. A total of 150 postmenopausal women aged ≥50 years referred for colposcopy due to abnormal cervical screening results will be randomised 1:1 to either pretreatment with vaginal application of Vagifem 30 µg or placebo once a day for 14 days prior to colposcopy. The primary outcome will be to compare the percentage of women in the two groups with a visible transformation zone at colposcopy, and biopsies representative of the transformation zone. Secondary outcomes will be the proportion of detected cervical intraepithelial neoplasia grade 2 or higher in the cervical biopsies; the proportion of diagnostics cone biopsies; the patients' report on possible side effects and compliance to the pretreatment. ETHICS AND DISSEMINATION The study has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (1-10-72-34-22), the Central Denmark Regions' Research Unit (1-16-02-72-22) and The Danish Health Authority (Danish Medicine Agency; 2022015030). The study's EudraCT number is (1-23-456; 2022-000269-42) and it is registered on www. CLINICALTRIALS gov. The local Good Clinical Practice (GCP) unit will supervise and monitor the study closely before, during and after the study period. Findings will be disseminated in peer-reviewed scientific journals and presented in relevant conferences. TRIAL REGISTRATION NUMBER NCT05283421.
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Affiliation(s)
- Vibe Munk Bertelsen
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Tranberg
- University Research Clinic for Cancer Screening and Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Berit Booth
- Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark
- Department of Gynecology and Obstetrics, Odense University, Odense, Denmark
| | - Pinar Bor
- Department of Gynecology and Obstetrics, Aarhus University, Aarhus, Denmark
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Goodman A. Age cutoffs for cervical cancer screening: good medicine or ageism? Menopause 2023; 30:885-886. [PMID: 37582300 DOI: 10.1097/gme.0000000000002240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Affiliation(s)
- Annekathryn Goodman
- From the Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA
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Tranberg M, Petersen LK, Hammer A, Elfström M, Blaakær J, Jørgensen SF, Bennetsen MH, Jensen JS, Andersen B. Value of a catch-up HPV test in women aged 65 and above: A Danish population-based nonrandomized intervention study. PLoS Med 2023; 20:e1004253. [PMID: 37410699 DOI: 10.1371/journal.pmed.1004253] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/31/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus (HPV) test is replacing cytology as the primary cervical cancer screening test due to superior sensitivity, but in most countries women ≥65 years have never had an HPV test despite they account for around 50% of cervical cancer deaths. We explored the effect of a catch-up HPV test among 65- to 69-year-old women without previous record of HPV-based screening. METHODS AND FINDINGS This population-based nonrandomized intervention study (quasi-experimental design) included Danish women aged 65 to 69 with no record of cervical cancer screening in the last ≥5.5 years and no HPV-exit test at age 60 to 64 at the time of study inclusion. Eligible women residing in the Central Denmark Region were invited for HPV screening either by attending clinician-based sampling or requesting a vaginal self-sampling kit (intervention group, n = 11,192). Women residing in the remaining four Danish regions received standard care which was the opportunity to have a cervical cytology collected for whatever reason (reference group, n = 33,387). Main outcome measures were detection of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) per 1,000 women eligible for the screening offer and the benefit-harm ratio of the intervention and standard practice measured as the number of colposcopies needed to detect one CIN2+ case. The minimum follow-up time was 13 months for all tested women (range: 13 to 25 months). In the intervention group, 6,965 (62.2%) were screened within 12 months from the date of study inclusion and 743 (2.2%) women had a cervical cytology collected in the reference group. The CIN2+ detection was significantly higher in the intervention group (3.9, 95% confidence interval (CI): [2.9, 5.3]; p < 0.001; n = 44/11,192) as compared to the reference group (0.3, 95% CI: [0.2, 0.6]; n = 11/33,387). For the benefit-harm ratio, 11.6 (95% CI: [8.5, 15.8]; p = 0.69; n = 511/44) colposcopies were performed to detect one CIN2+ in the intervention group as compared to 10.1 (95% CI: [5.4, 18.8]; n = 111/11) colposcopies in the reference group. The study design entails a risk of confounding due to the lack of randomization. CONCLUSIONS The higher CIN2+ detection per 1,000 eligible women in the intervention group supports that a catch-up HPV test could potentially improve cervical cancer prevention in older women. This study informs the current scientific debate as to whether women aged 65 and above should be offered a catch-up HPV test if they never had an HPV test. TRIAL REGISTRATION ClinicalTrials.gov NCT04114968.
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Affiliation(s)
- Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, Southern University of Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
| | - Miriam Elfström
- Center for Cervical Cancer Prevention, Karolinska University Hospital, Stockholm, Sweden
- Regional Cancer Center of Stockholm-Gotland, Stockholm, Sweden
| | - Jan Blaakær
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Susanne Fogh Jørgensen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | | | - Jørgen Skov Jensen
- Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Blomberg K, Hälleberg-Nyman M. Experiences of human papillomavirus self-sampling by women >60 years old: A qualitative study. Health Expect 2023; 26:818-826. [PMID: 36633121 PMCID: PMC10010077 DOI: 10.1111/hex.13707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) self-sampling has shown to be acceptable and feasible across cultures and effective in reaching women who do not participate in regular cervical cancer screening. However, most of these studies have included younger women. There is a lack of knowledge of how older women reason about HPV self-sampling. OBJECTIVE The aim of this study was to describe how women (>60 years old) experience the offering of self-sampling of HPV, compared to having a sample collected by a healthcare professional. DESIGN AND PARTICIPANTS The study had a qualitative explorative design. Four focus group discussions were conducted with women 60-69 years old (n = 22). Data were analysed using principles of interpretive description. RESULTS Five themes were identified: self-sampling-convenient and without pain, lack of knowledge, worries related to HPV self-sampling, need for information and taking a societal perspective. CONCLUSION Women aged >60 years found that HPV self-sampling was convenient and easy to perform. Further, they stressed the importance of being able to remain in the screening programme in advanced age and that self-sampling could be a possible solution. This study also revealed a lack of knowledge among women in this age group regarding HPV infection, how the disease is transmitted and its relation to cervical cancer. PUBLIC CONTRIBUTION Women who had performed HPV self-sampling participated in the focus group discussion.
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Affiliation(s)
- Karin Blomberg
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Hälleberg-Nyman
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Gustafson LW, Tranberg M, Christensen PN, Brøndum R, Wentzensen N, Clarke MA, Andersen B, Petersen LK, Bor P, Hammer A. Clinical utility of p16/Ki67 dual-stain cytology for detection of cervical intraepithelial neoplasia grade two or worse in women with a transformation zone type 3: A cross-sectional study. BJOG 2023; 130:202-209. [PMID: 35686564 PMCID: PMC10084097 DOI: 10.1111/1471-0528.17248] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the clinical utility of p16/Ki67 dual-stain (DS) compared with cytology for detecting cervical intraepithelial lesion grade two or worse (CIN2+) in women with a transformation zone type 3 (TZ3). DESIGN Cross-sectional study. SETTING Colposcopy clinics in Central Denmark Region. POPULATION Women aged 45 years or older referred for colposcopy because of an abnormal screening test. METHODS All women had a cervical sample collected for cytology and DS testing and underwent large-loop excision of the transformation zone (LLETZ). MAIN OUTCOME MEASURE Sensitivity, specificity and negative (NPV) and positive (PPV) predictive values of DS for CIN2+ detection were compared to those of cytology. RESULTS Of 166 women eligible, 93 (56.0%) were included in the final analysis. Median age was 68 years (interquartile range [IQR] 63.4-70.5 years). Most women were postmenopausal (95.7%) and referred based on a positive human papillomavirus screening test (86.0%). Fifty-two women (55.9%) were DS-positive, 29 (55.8%) of whom had CIN2+ detected. Twenty-seven (29.0%) women had atypical squamous cells of undetermined significance or worse (ASC-US+), and CIN2+ was detected in 21 women (77.8%). DS had a higher sensitivity (96.7% versus 70.0% p = 0.021) and NPV (97.6% versus 86.4%, p = 0.018) compared with cytology for CIN2+ detection. In contrast, the specificity (63.5% versus 90.5% p < 0.001) and PPV (55.8% versus 77.8%, p = 0.001) were lower for DS compared with cytology. CONCLUSIONS Dual stain may be a valuable risk marker to guide clinical management of women with a TZ3. The superior NPV of DS suggests that a diagnostic excision may safely be avoided in DS-negative women.
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Affiliation(s)
- Line Winther Gustafson
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | | | - Rikke Brøndum
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Nicolas Wentzensen
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Megan A Clarke
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynaecology, Odense University Hospital and Open Patient Data Explorative Network, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pinar Bor
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynaecology, Randers Regional Hospital, Randers, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynaecology, NIDO Denmark, Gødstrup Hospital, Herning, Denmark
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Gustafson LW, Hammer A, Bennetsen MH, Kristensen C, Majeed H, Petersen LK, Andersen B, Bor P. Cervical intraepithelial neoplasia in women with transformation zone type 3: cervical biopsy versus large loop excision. BJOG 2022; 129:2132-2140. [PMID: 35488417 PMCID: PMC9796102 DOI: 10.1111/1471-0528.17200] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3). DESIGN Multicentre cross-sectional study. SETTING Three colposcopy clinics in the Central Denmark Region. POPULATION Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy. METHODS Women had multiple biopsies taken and an LLETZ was performed. MAIN OUTCOME MEASURES Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens. RESULTS Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95% CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95% CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95% CI 73.6-89.2%). CONCLUSIONS CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.
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Affiliation(s)
- Line Winther Gustafson
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark,Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Anne Hammer
- Department of Clinical MedicineAarhus UniversityHerningDenmark,Department of Obstetrics and GynaecologyGødstrup HospitalHerningDenmark
| | | | | | - Huda Majeed
- Department of Obstetrics and GynaecologyViborg Regional HospitalViborgDenmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and GynaecologyOdense University HospitalOdenseDenmark,Open Patient data Explorative Network, Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional HospitalUniversity Research Clinic for Cancer ScreeningRandersDenmark,Department of Clinical MedicineAarhus UniversityHerningDenmark
| | - Pinar Bor
- Department of Clinical MedicineAarhus UniversityHerningDenmark,Department of Obstetrics and GynaecologyRanders Regional HospitalRandersDenmark
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Davies-Oliveira JC, Smith MA, Grover S, Canfell K, Crosbie EJ. Eliminating Cervical Cancer: Progress and Challenges for High-income Countries. Clin Oncol (R Coll Radiol) 2021; 33:550-559. [PMID: 34315640 DOI: 10.1016/j.clon.2021.06.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
In 2020, the World Health Organization launched a major initiative to eliminate cervical cancer globally. The initiative is built around the three key pillars of human papillomavirus (HPV) vaccination, cervical screening and treatment, with associated intervention targets for the year 2030. The '90-70-90' targets specify that 90% of adolescent girls receive prophylactic HPV vaccination, 70% of adult women receive a minimum twice-in-a-lifetime cervical HPV test and 90% receive appropriate treatment for preinvasive or invasive disease. Modelling has shown that if these targets are met, the elimination of cervical cancer, defined as fewer than four cases per 100 000 women per annum, will be achieved within a century. Many high-income countries are well positioned to eliminate cervical cancer within the coming decades, but few have achieved '90-70-90' and many challenges must still be addressed to deliver these critical interventions effectively. This review considers the current status of cervical cancer control in relation to each of the three elimination pillars in high-income countries and discusses some of the developments that will assist countries in reaching these ambitious targets by 2030.
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Affiliation(s)
- J C Davies-Oliveira
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Faculty of Biology, Medicine and Health, Manchester, UK; Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M A Smith
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - S Grover
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia; Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia.
| | - E J Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, University of Manchester, Faculty of Biology, Medicine and Health, Manchester, UK; Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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