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Beyene DA, Ayele SG, Wubneh HD, Tsige AW. Male support for cervical cancer screening in Debre Berhan City Ethiopia a community based cross sectional survey. Sci Rep 2024; 14:18302. [PMID: 39112655 PMCID: PMC11306371 DOI: 10.1038/s41598-024-69439-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024] Open
Abstract
Male partner involvement strongly influences a woman's decision to undergo cervical cancer screening. Women of low socioeconomic status are disproportionately affected by cervical cancer. Women living in low-and middle-income countries often encounter resistance from their partners regarding participation in cervical cancer screening. The lack of men's support for sexual and reproductive health programs, including cervical cancer screening, creates a barrier to women's utilization of health services. To assess Ethiopian men's awareness, knowledge, perceptions, and attitudes toward cervical cancer screening and their support to their female partners during screening. A community-based cross-sectional survey was conducted from June 20, 2023, to August 04, 2023. A multistage sampling procedure was used to recruit 614 male survey participants. Descriptive statistics were used to summarize sociodemographic data. Univariate and multivariate regression analyses were performed to measure the associations between the dependent and independent variables. A p-value of less than 0.05 was considered statistically significant. In this survey, 58.5% (359) of participants supported their partners for cervical cancer screening. More than half 55.9% (343) of the participants had an awareness of cervical cancer disease and 47.2% (290) participants knew the risk factors associated with the development of cervical cancer. In addition to that, 66.8% (410) of men have a positive attitude towards screening and encourage their wives to get screened if they notice symptoms of cervical cancer. Regarding the perceptions of cervical cancer, 37.0% (227) of male participants believed that their female partners were at risk of developing the disease, while 38.3% (235) of men believed that cervical cancer screening was only necessary if the woman showed symptoms. Completion of higher education (AOR = 3.75, 95% CI 1.60-8.79, p = 0.002), living with other people (AOR = 0.09, 95% CI 0.03-0.29, p < 0.0001), not being tested for HIV (AOR = 0.26, 95% CI 0.10-0.74, p = 0.011), and having information about cervical cancer (AOR = 3.33, 95% CI 1.36-8.15, p = 0.009) were statistically significantly associated with men's support for their partners in cervical cancer screening. Men's awareness, knowledge, and perceptions of cervical cancer screening were low. On the other hand, men have a positive attitude towards screening and encourage their wives to get screened if they notice symptoms of cervical cancer. This survey will serve as a basis for the development of further strategies and action plans to promote and support male participation in cervical cancer screening in Ethiopia. This can be achieved through the development of strategic plans, including public campaigns, raising awareness among social and community leaders, involving non-governmental organizations focusing on women's health, and community education.
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Affiliation(s)
- Dessale Abate Beyene
- Department of Pharmacy, Asrat Woldeyes Health Science Campus, Debre Berhan University, P.O. Box 445, 1000, Debre Berhan, Ethiopia.
| | - Siraye Genzeb Ayele
- Department of Midwifery, School of Nursing and Midwifery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Henok Dessie Wubneh
- School of Medicine, College of Medicine and Health Sciences, University of Gonder, Gonder, Ethiopia
| | - Abate Wondesen Tsige
- Department of Pharmacy, Asrat Woldeyes Health Science Campus, Debre Berhan University, P.O. Box 445, 1000, Debre Berhan, Ethiopia
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Mungo C, Adewumi K, Ellis G, Rop M, Adoyo E, Zou Y, Rahangdale L. Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya. Ecancermedicalscience 2024; 18:1719. [PMID: 39021542 PMCID: PMC11254395 DOI: 10.3332/ecancer.2024.1719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Indexed: 07/20/2024] Open
Abstract
Background Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible and resource-appropriate treatment approaches, including self-administered therapies. Methods A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of human papillomavirus and cervical cancer, their views on screening and treatment and their attitudes toward self-administered therapies. Focus group discussions (FGDs) with a subset of the survey participants further explored their treatment preferences and perceptions. Results Two hundred fourteen men participated in the survey, and 39 men participated in FGDs. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness and privacy. Preferences varied between two potential therapies, 5-Fluorouracil and Artesunate, based on their administration frequency, duration and abstinence requirements. Qualitative findings largely supported the quantitative analysis. Conclusion The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Grace Ellis
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Mercy Rop
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Yating Zou
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Stroetmann CY, Gizaw M, Alemayehu R, Wondimagegnehu A, Rabe F, Santos P, Mchome B, Mmbaga BT, Addissie A, Kantelhardt EJ. Adherence to Treatment and Follow-Up of Precancerous Cervical Lesions in Ethiopia. Oncologist 2024; 29:e655-e664. [PMID: 38394385 PMCID: PMC11067800 DOI: 10.1093/oncolo/oyae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND In Ethiopia, both incidence and mortality of cervical cancer are relatively high. Screening services, which were implemented during the past few years, are currently being expanded. The World Health Organization recommends patients with a positive VIA (visual inspection with acetic acid) result should immediately receive treatment followed by rescreening after 1 year as precancerous lesions can reoccur or become residential despite treatment. MATERIALS AND METHODS Screening logbooks dating between 2017 and 2020 were retrospectively reviewed in 14 health facilities of Addis Ababa and Oromia region. Data for 741 women with a VIA-positive result were extracted and those women were asked to participate in a questionnaire-based phone interview to gain insights about adherence to treatment and follow-up. Data were analyzed using descriptive methods and then fitted into 2 generalized linear models to test variables for an influence on adherence to follow up. RESULTS Around 13 800 women had received a VIA screening, of which approximately 820 (5.9%) were VIA positive. While over 90% of women with a positive screen received treatment, only about half of the treated patients returned for a follow-up examination. After treatment, 31 women had a VIA-positive re-screen. We found that educational status, age over 40, no/incorrect follow-up appointment, health facility-related barriers, and use of reminders are important drivers of adherence to follow up. CONCLUSION Our results revealed that adherence to treatment after VIA positive screening is relatively high whereas adherence to follow up recommendations still needs improvement. Reminders like appointment cards and phone calls can effectively reduce the loss of follow-up.
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Affiliation(s)
- Clara Yolanda Stroetmann
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Muluken Gizaw
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- NCD Working Group, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rahel Alemayehu
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abigiya Wondimagegnehu
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- NCD Working Group, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Friedemann Rabe
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Pablo Santos
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Bariki Mchome
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina Theophil Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Adamu Addissie
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- NCD Working Group, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Institute for Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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Nakisige C, de Fouw M, Nakalembe M, Orem J, Atukonyera D, Musheshe M, Koot J, de Zeeuw J, Beltman J, Stekelenburg J. Baseline knowledge on risk factors, symptoms and intended behavior of women and men towards screening and treatment of cervical cancer in rural Uganda: a cross-sectional study. BMC Cancer 2024; 24:450. [PMID: 38605317 PMCID: PMC11008004 DOI: 10.1186/s12885-024-12223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Knowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands/decision makers) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behavior of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms. METHODS This cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30-49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behavior and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men. RESULTS A total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men. Lack of decision making by women was associated with low knowledge of risk factors (X2 = 14.542; p = 0.01), low education (X2 = 36.05, p < 0.01) and older age (X2 = 17.33, p < 0.01). Men had better help seeking behavior than women (X2 = 64.96, p < 0.01, OR = 0.39, 95% CI: 0.31-0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X2 = 27.28, p < 0.01, OR = 0.52, CI (0.40-0.67). CONCLUSION The baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behavior towards screening was also positive but screening uptake was very low. This study suggests developing messages on multiple interventions to promote screening behavior in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly.
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Affiliation(s)
- Carolyn Nakisige
- Department of Gynaecologic-Oncology, Uganda Cancer Institute, Kampala, Uganda.
| | - Marlieke de Fouw
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Jackson Orem
- Department of Gynaecologic-Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Dan Atukonyera
- Uganda Rural Development Training Program, Kagadi, Uganda
| | | | - Jaap Koot
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine de Zeeuw
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jogchum Beltman
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Mungo C, Kachoria AG, Adoyo E, Zulu G, Goraya SK, Omoto J, Osongo C, Ferrari RM. "ARVs is for HIV and cream is for HPV or precancer:" Women's Perceptions and Perceived Acceptability of Self-Administered Topical Therapies for Cervical Precancer Treatment: A Qualitative Study from Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.11.24304083. [PMID: 38559146 PMCID: PMC10980133 DOI: 10.1101/2024.03.11.24304083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Women in low- and middle-income countries (LMICs) bear a disproportionate burden of global incidence and deaths from cervical cancer, despite being a preventable disease. Prevention efforts in LMICs are hindered in part by lack of access to cervical precancer treatment, due to weak health infrastructure and a lack of adequate human resources to deliver current provider-administered precancer treatments. Innovative strategies are urgently needed to close the cervical precancer treatment gap in LMICs, including the use of self-administered topical therapies for which efficacy evidence is available from high-income settings. We investigated African women's perceptions and perceived acceptability of these therapies for cervical precancer treatment. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with women ages 25-65 years undergoing cervical cancer screening or precancer treatment in Kisumu, Kenya. The FGDs explored women's experiences with screening and precancer treatment, their acceptability of topical therapies for precancer treatment, and perceived barriers and facilitators to uptake. The FGDs were moderated by local qualitative research assistants, conducted in local languages, transcribed, coded, and analyzed using qualitative description using NVIVO software. Results Twenty-nine women participated, with a mean age of 35.4 years (SD 6.5). All had undergone cervical cancer screening, and 25 (83%) had a history of precancer treatment with ablation or excision. Multiple themes were identified related to women's perceptions of topical therapies. Participants were highly receptive of topical treatments, with many favoring the option of self-administration compared to provider-administration of such therapies. Self-administration of topical therapies was felt to help address challenges associated with current treatment methods, including difficulty in access, pain with procedures, cost, and lack of privacy with pelvic exams. Participants had a preference for topical therapies that are used less frequently compared to those used daily. Conclusions Among Kenyan women with a history of cervical precancer treatment, self-administered topical therapies for precancer are acceptable and have the potential to address barriers, including access, privacy, and cost, that hinder precancer treatment in LMICs. If supported by efficacy studies in LMICs, self-administered topical therapies offer a scalable approach to closing the precancer treatment gap in LMICs. Trial registration Not applicable.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Aparna Ghosh Kachoria
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | | | - Graham Zulu
- Butler Institute for Families, University of Denver, Denver, CO 80210, USA
| | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | | | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Mungo C, Adewumi K, Adoyo E, Zulu G, Goraya SK, Ogollah C, Omoto J, Ferrari RM, Rahangdale L. "There is nothing that can prevent me from supporting her:" men's perspectives on their involvement and support of women's use of topical therapy for cervical precancer treatment in Kenya. Front Oncol 2024; 14:1360337. [PMID: 38532929 PMCID: PMC10964769 DOI: 10.3389/fonc.2024.1360337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 03/28/2024] Open
Abstract
Purpose Cervical cancer disproportionately impacts women in low- and middle-income countries (LMICs). The World Health Organization's (WHO) 90/70/90 strategy aims to eliminate cervical cancer by 2030 by increasing HPV vaccination coverage to 90%, screening 70% of eligible women, and effectively treating 90% of those with abnormal results by 2030, potentially preventing 62 million deaths in LMICs. LMICs, however, struggle with limited access to cervical precancer treatment, in part due to a lack of trained professionals and weak health systems. Effective non-surgical, self-administered, which have demonstrated efficacy in high-income countries, could bridge the treatment gap in LMICs and may be more scalable and cost-effective than provider-administered therapies. To inform feasibility studies in LMICs, data are needed on the role of male partners in influencing the acceptability and uptake of self-administered topical therapies, including their support of recommended abstinence and contraception guidelines associated with these therapies. Methods Between November 2022 and April 2023, we conducted five focus group discussions (FGDs) with men aged 25 to 65 years in Kenya to explore their perspective and perceived support regarding their female partners using topical self-administered therapies for cervical precancer treatment. The FGDs were moderated by local qualitative research assistants and conducted in local languages, transcribed, coded, and analyzed using qualitative description. Results Thirty-nine male participants meeting the eligibility criteria participated in five FGDs. The mean age of participants was 42.5 years. Most participants, 79.5%, had a female partner with a history of cervical precancer treatment, 5.1% did not, and 15.4% were unsure of their female partner's prior precancer treatment history. The study aimed to assess men's support of their female partners' use of topical therapies for treating cervical precancer. We find that male participants strongly express acceptance and willingness to support their wives or partners in using such therapies, if available. Reported supportive behavior included permitting the use of the therapies and support of maintaining abstinence during the recommended times. Additionally, participants desired male involvement in clinic and community-based education about topical therapies to facilitate widespread support. Conclusion The use of self-administered topical therapies for cervical precancer treatment, if supported by efficacy studies in LMICs, may support achieving the WHO's 2030 goal of 90% treatment access. We find that with adequate education, men express overwhelming support of their female partner's use of topical therapies, including adherence to abstinence and contraception guidelines.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Graham Zulu
- University of Denver, Denver, CO, United States
| | - Supreet Kaur Goraya
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Mungo C, Ellis GK, Rop M, Zou Y, Omoto J, Rahangdale L. Perceived acceptability of self-administered topical therapy for cervical precancer treatment among women undergoing cervical cancer screening in Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.05.24303779. [PMID: 38585806 PMCID: PMC10996722 DOI: 10.1101/2024.03.05.24303779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Purpose Innovative strategies are urgently needed to meet the World Health Organization's 2030 target of treating 90% of women with precancerous cervical lesions, especially in countries most affected by cervical cancer. We assessed the acceptability of self-administered intravaginal therapies for treating cervical precancer in women undergoing cervical cancer screening and precancer treatment in Kenya. Methods We conducted a cross-sectional study among women aged 18 to 65 years undergoing cervical cancer screening or precancer treatment between January and October 2023 in Kisumu County, Kenya. Participants completed a questionnaire about their perceptions and perceived acceptability of self- or provider-administered topical therapies for cervical precancer treatment. Quantitative data were summarized using descriptive statistics. Results A total of 379 questionnaires were completed. The median age of participants was 35 years (IQR 25-62), 62% had a primary education or less, and 71% earned $5 or less daily. All participants had been screened for cervical cancer, and 191 (51%) had received precancer treatment, primarily thermal ablation. Ninety-eight percent of participants were willing to use a self-administered intravaginal therapy for cervical precancer, if available. The majority, 91%, believed their male partner would support their use. Given a choice, 63% preferred self-admiration at home compared to provider-administration of a topical therapy in the clinic, citing time and cost savings. In multivariate analysis, married women were more likely to expect partner support for self-administration than single women. Participants preferred a therapy used less frequently but for a longer duration, compared to daily use therapy with a shorter duration of use. Conclusions Self-administered intravaginal therapies for cervical precancer treatment are highly acceptable among women undergoing screening and precancer treatment in Kenya.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, North Carolina, USA
| | - Grace K Ellis
- School of Medicine, University of North Carolina Chapel Hill, North Carolina, USA
| | - Mercy Rop
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Yating Zou
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine. Kisumu, Kenya
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, North Carolina, USA
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Lee F, McGue S, Chapola J, Dunda W, Tang JH, Ndovie M, Msowoya L, Mwapasa V, Smith JS, Chinula L. Experiences of women participating in a human papillomavirus-based screen-triage-and treat strategy for cervical cancer prevention in Malawi. Front Oncol 2024; 14:1356654. [PMID: 38476363 PMCID: PMC10927745 DOI: 10.3389/fonc.2024.1356654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/26/2024] [Indexed: 03/14/2024] Open
Abstract
Objective To explore the experiences of Malawian women who underwent a human papillomavirus (HPV)-based screen-triage-treat algorithm for cervical cancer (CxCa) prevention. This algorithm included GeneXpert® HPV testing of self-collected vaginal samples, visual inspection with acetic acid (VIA) and colposcopy for HPV-positive women, and thermal ablation of ablation-eligible women. Method In-depth interviews were conducted with participants of a trial that evaluated the feasibility of a HPV-based screen-triage-treat algorithm among women living with HIV and HIV negative women in Lilongwe, Malawi. Participants were recruited from 3 groups: 1) HPV-negative; 2) HPV-positive/VIA-negative; 3) HPV-positive/VIA-positive and received thermal ablation. Interviews explored baseline knowledge of CxCa and screening, attitudes towards self-collection, and understanding of test results. Content analysis was conducted using NVIVO v12. Results Thematic saturation was reached at 25 interviews. Advantages of HPV self-collection to participants were convenience of sampling, same-day HPV results and availability of same-day treatment. There was confusion surrounding HPV-positive/VIA-negative results, as some participants still felt treatment was needed. Counseling, and in particular anticipatory guidance, was key in helping participants understand complex screening procedures and results. Overall, participants expressed confidence in the HPV screen-triage-treat strategy. Discussion HPV testing through self-collected samples is a promising tool to increase CxCa screening coverage. A multi-step screening algorithm utilizing HPV self-testing, VIA triage and thermal ablation treatment requires proper counseling and anticipatory guidance to improve patient understanding. Incorporating thorough counseling in CxCa screening programs can change women's perspectives about screening, build trust in healthcare systems, and influence healthcare seeking behavior towards routine screening and prevention.
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Affiliation(s)
- Fan Lee
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
| | - Shannon McGue
- Department of Medicine, Duke University, Durham, NC, United States
| | - John Chapola
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
| | - Wezzie Dunda
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Jennifer H. Tang
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Margret Ndovie
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Lizzie Msowoya
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Victor Mwapasa
- Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jennifer S. Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Lameck Chinula
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, United States
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
- Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Blantyre, Malawi
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Mungo C, Adewumi K, Ellis G, Rop M, Adoyo E, Zou Y, Rahangdale L. Men's perceptions and perceived acceptability of their female partner's use of self-administered intravaginal therapies for treatment of cervical precancer in Kenya. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.06.24302397. [PMID: 38370772 PMCID: PMC10871376 DOI: 10.1101/2024.02.06.24302397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background Cervical cancer continues to be a major health issue in low- and middle-income countries (LMICs). Despite increasing access to screening, access to precancer treatment remains a significant challenge in LMICs, highlighting a need for innovative, accessible, and resource-appropriate treatment approaches, including self-administered therapies. Methods A cross-sectional mixed-methods study was conducted among men aged 25-65 with a current female partner in Kisumu County, Kenya. Participants were sequentially recruited and surveyed to evaluate their understanding of HPV and cervical cancer, their views on screening and treatment, and their attitudes toward self-administered therapies. Focus group discussions with a subset of the survey participants further explored their treatment preferences and perceptions. Results Two hundred fourteen men participated in the survey, and 39 men participated in focus group discussions. The median age was 39 years, and 51% had a primary school education or less. Most (96%) were in a committed relationship, and 74% earned $10 or less daily. There was strong support for self-administered topical therapies, with 98% willing to support their partners using such treatments if available. Additionally, most participants were open to supporting necessary abstinence or condom use, though 76% believed their partners might hesitate to request condom use. When given an option, most preferred their partner to self-administer such therapies at home compared to provider administration at a health facility, citing convenience, cost-effectiveness, and privacy. Preferences varied between two potential therapies, 5-Fluorouracil (5FU) and Artesunate, based on their administration frequency, duration, and abstinence requirements. Qualitative findings largely supported the quantitative analysis. Conclusions The study demonstrates strong support for self-administered topical therapies for cervical precancer among Kenyan men. Additional research on acceptability, feasibility, and efficacy in different LMICs could pave the way for these therapies to help bridge current cervical precancer treatment gaps in these settings.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Konyin Adewumi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Grace Ellis
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Mercy Rop
- Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Yating Zou
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Evina Bolo S, Kenfack B, Wisniak A, Tankeu G, Yakam V, Moukam A, Sormani J, Stoll B, Vassilakos P, Petignat P. Factors influencing cervical cancer re-screening in a semi-rural health district of Cameroon: a cohort study. BMC Womens Health 2024; 24:76. [PMID: 38281960 PMCID: PMC10822157 DOI: 10.1186/s12905-024-02917-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/19/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Screening participation at recommended intervals is a crucial component of cervical cancer prevention effectiveness. However, little is known regarding the rate of re-screening in a Sub-Saharan context. This study aimed to estimate the re-screening rate of women in a semi-rural after an initial HPV-based screening and identify factors that influence adherence. METHODS This cohort study at the Annex Regional Hospital of Dschang enrolled women screened for cervical cancer over 5 years ago and due for re-screening. Women who initially tested HPV-positive (n = 132) and a random sample of HPV-negative women (n = 220) participated in a telephone survey between October 2021 and March 2022 to assess re-screening participation and reasons. Sociodemographic factors were collected, and associations with rescreening were evaluated. RESULTS A total of 352 participants aged under 50 years (mean age 37.4 years) were contacted, and 203 (58.0%) completed the survey. The proportion of women who complied with the screening recommendation was 34.0% (95% CI 27.5% - 40.5%), The weighted re-screening proportion was 28.4%. Age, marital status, education level, type of employment, and place of residence were not associated with the rate of re-screening. Main reported barriers to re-screening were lack of information (39.0%), forgetfulness (39.0%), and impression of being in good health (30.0%). Women who remembered the recommended screening interval were 2 to 3 times more likely to undergo re-screening (aOR (adjusted odds ratio) = 2.3 [1.2-4.4], p = 0.013). Human papilloma virus- positive status at the initial screening was also associated with the re-screening((aOR) (95% CI): 3.4 (1.8-6.5). CONCLUSION Following an initial Human Papilloma Virus-based screening campaign in the West Region of Cameroon, one third of women adhered to re-screening within the recommended timeframe. Existing screening strategies would benefit from developing better information approaches to reinforce the importance of repeated cervical cancer screening.
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Affiliation(s)
- Sophie Evina Bolo
- Department of Gynaecology and Obstetrics, Annex Regional Hospital of Dschang, Dschang, Cameroon.
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
| | - Bruno Kenfack
- Department of Gynaecology and Obstetrics, Annex Regional Hospital of Dschang, Dschang, Cameroon
- Department of Obstetrics, Gynaecology and Maternal Health, University of Dschang, Dschang, Cameroon
| | - Ania Wisniak
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
| | - Gilles Tankeu
- Department of Gynaecology and Obstetrics, Annex Regional Hospital of Dschang, Dschang, Cameroon
- Global Research Agency, Dschang, Cameroon
| | - Virginie Yakam
- Department of Gynaecology and Obstetrics, Annex Regional Hospital of Dschang, Dschang, Cameroon
| | - Alida Moukam
- Department of Gynaecology and Obstetrics, Annex Regional Hospital of Dschang, Dschang, Cameroon
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Jessica Sormani
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
- HES-SO University of Applied Sciences and Arts Western, Delémont, Switzerland
| | - Beat Stoll
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
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11
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Kajabwangu R, Ssedyabane F, Tusubira D, Maling S, Kakongi N, Turyakira E, Namuli A, Galiwango M, Randall TC. High Rate of Loss to Follow-Up Among Patients Undergoing Treatment for Premalignant Cervical Lesions at Mbarara Regional Referral Hospital, Southwestern Uganda: A Retrospective Cohort Study. Cureus 2023; 15:e46542. [PMID: 37927695 PMCID: PMC10625478 DOI: 10.7759/cureus.46542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND For a cervical cancer control program to be effective in reducing the incidence of the disease, there should be high compliance to treatment and follow-up of women diagnosed with precursor lesions. Screening programs in low-resource countries such as Uganda are challenged by poor adherence to follow-up following treatment for premalignant cervical lesions. This study sought to describe the burden and factors associated with loss to follow-up among women undergoing treatment for premalignant cervical lesions at a tertiary hospital in southwestern Uganda. METHODS This was a retrospective cohort study. We reviewed the registers at the Mbarara Regional Referral Hospital (MRRH) cervical cancer clinic for a period of four years from January 2017 to December 2020. Data on age, district of residence, diagnosis, date of diagnosis, date and type of initial treatment, and date of follow-up visit were collected. We also captured data on whether patients returned on the scheduled follow-up date or within three months after the scheduled follow-up date. We defined loss to follow-up as failure to return for follow-up either on the scheduled date or within three months after the scheduled date. RESULTS Out of the 298 patients who underwent treatment for premalignant cervical lesions in the study period, 227 (76.2%) did not return for follow-up at one year. At bivariate analysis, failure to attend the review visit at six weeks predicted the loss to follow-up at one year following treatment for premalignant lesions almost perfectly (risk ratio (RR)=2.84, 95% confidence interval (CI): 2.18-3.71, p<0.001). Negative HIV serostatus and receiving thermocoagulation slightly increased the risk of getting lost to follow-up, while being more than 45 years old reduced the odds. At multivariate analysis, treatment with thermocoagulation (adjusted risk ratio (aRR)=1.21, 95% CI: 1.07-1.36, p=0.03) was associated with loss to follow-up at one year. CONCLUSION The proportion of women who did not return for follow-up at one year following treatment for premalignant cervical lesions at Mbarara Regional Referral Hospital is very high. There is a need to implement strategies such as telephone-aided reminders to prompt patients to return for follow-up following treatment for premalignant cervical lesions.
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Affiliation(s)
- Rogers Kajabwangu
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, UGA
| | - Frank Ssedyabane
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, UGA
| | - Deusdedit Tusubira
- Department of Biochemistry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Samuel Maling
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Natthan Kakongi
- Department of Biochemistry, Mbarara University of Science and Technology, Mbarara, UGA
| | - Eleanor Turyakira
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, UGA
| | - Alexcer Namuli
- Department of Obstetrics and Gynecology, Mbarara Regional Referral Hospital, Mbarara, UGA
| | - Martin Galiwango
- Department of Electrical and Electronics Engineering, Faculty of Applied Sciences and Technology, Mbarara University of Science and Technology, Mbarara, UGA
| | - Thomas C Randall
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, USA
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de Fouw M, Stroeken Y, Niwagaba B, Musheshe M, Tusiime J, Sadayo I, Reis R, Peters AAW, Beltman JJ. Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda. PLoS One 2023; 18:e0280052. [PMID: 36706114 PMCID: PMC9882699 DOI: 10.1371/journal.pone.0280052] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 12/20/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Evidence-based preventive strategies for cervical cancer in low-resource setting have been developed, but implementation is challenged, and uptake remains low. Women and girls experience social and economic barriers to attend screening and human papillomavirus (HPV) vaccination programs. Male support has been proven successful in uptake of other reproductive healthcare services. This qualitative study with focus groups aimed to understand the perspectives of males on cervical cancer screening and HPV vaccination in Western-Uganda This knowledge could be integrated into awareness activities to increase the attendance of cervical cancer screening and HPV vaccination programs. MATERIALS AND METHODS Focus group discussions were conducted with men aged 25 to 60 years, who were married and/or had daughters, in Kagadi district, Mid-Western Uganda. All interviews were transcribed verbatim and thematically analyzed using an inductive approach. RESULTS Eleven focus group discussions were conducted with 67 men. Men were willing to support their wives for screening and their daughters for HPV vaccination. Misperceptions such as family planning and poor personal hygiene leading to cervical cancer, and misperception of the preventative aspect of screening and vaccination were common. Women with cervical cancer suffer from stigmatization and family problems due to loss of fertility, less marital sexual activity, domestic violence and decreased economic productivity. CONCLUSIONS Ugandan men were willing to support cervical cancer prevention for their wives and daughters after being informed about cervical cancer. Limited knowledge among men about the risk factors and causes of cervical cancer, and about the preventative aspect of HPV vaccination and screening and their respective target groups, can limit uptake of both services. Screening and vaccination programs should actively involve men in creating awareness to increase uptake and acceptance of prevention.
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Affiliation(s)
- Marlieke de Fouw
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
- * E-mail:
| | - Yaël Stroeken
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ben Niwagaba
- Department of Technologies for Rural Transformation, African Rural University, Kagadi, Uganda
| | - Mwalimu Musheshe
- Department of Technologies for Rural Transformation, African Rural University, Kagadi, Uganda
| | - John Tusiime
- Department of Technologies for Rural Transformation, African Rural University, Kagadi, Uganda
| | - Isingoma Sadayo
- Department of Technologies for Rural Transformation, African Rural University, Kagadi, Uganda
| | - Ria Reis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands
- Children’s Institute, University of Cape Town, Cape Town, South Africa
| | | | - Jogchum Jan Beltman
- Department of Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
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13
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Soler M, Alfaro K, Masch RJ, Conzuelo Rodriguez G, Qu X, Wu S, Sun J, Hernández Jovel DM, Bonilla J, Puentes LO, Murillo R, Alonzo TA, Felix JC, Castle P, Cremer M. Safety and Acceptability of Three Ablation Treatments for High-Grade Cervical Precancer: Early Data From a Randomized Noninferiority Clinical Trial. JCO Glob Oncol 2022; 8:e2200112. [PMID: 36525620 PMCID: PMC10166394 DOI: 10.1200/go.22.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE This ongoing trial is comparing the efficacy and safety of three ablation treatments for cervical intraepithelial neoplasia grade 2 or higher. Here, we present early data regarding pain, side effects, and acceptability of CO2 gas-based cryotherapy (CO2), nongas cryotherapy, and thermal ablation (TA). Efficacy results are expected to become available in late 2023. MATERIALS AND METHODS This noninferiority randomized trial is taking place in El Salvador, China, and Colombia. Patients are 1,152 eligible women with biopsy-confirmed cervical intraepithelial neoplasia grade 2 or higher who will receive one of three ablation treatments. Pain is measured before, during, and after treatment with a visual analog scale (1-10). Side effects and acceptability are assessed at 6 weeks. RESULTS To date, 1,024 of 1,152 (89%) women were randomly assigned to treatment. The median pain level was higher during TA (4, IQR = 4) than CO2 (2, IQR = 4) or nongas cryotherapy (2, IQR = 4) (P < .01, range: 0-10). The most common post-treatment symptom was watery discharge, reported by 97.9% of women, and it lasted longer in the CO2 group than the other two treatments (in days, median [IQR]: CO2 = 20[20], nongas cryotherapy = 15[10], TA = 18[15], P < .01). Bleeding was reported more frequently in women treated with TA (27.6%) than CO2 (17.5) or nongas cryotherapy (18.7%) (P < .01). The majority of patients reported being very satisfied with the treatment they received at 6 weeks (91%) and again at 12 months post-treatment (97%). CONCLUSION Despite differences in pain and side effects across ablation treatments, all were safe and highly acceptable to patients. In addition to efficacy, considerations such as cost and portability may be more significant in choosing a treatment method.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Karla Alfaro
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Rachel J Masch
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | | | - Xinfeng Qu
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Suhui Wu
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Jingfen Sun
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | | | - Jairo Bonilla
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Luis Orlando Puentes
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Raúl Murillo
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Todd A Alonzo
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Philip Castle
- Divisions of Cancer Prevention and Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
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