Evaluation of portable colposcopy and human papillomavirus testing for screening of cervical cancer in rural China

Value of high‑risk human papillomavirus detection combined with colposcopy in the diagnosis of cervical cancer and precancerous lesions

In the present study, the diagnostic value of high risk-human papillomavirus (HR-HPV) combined with colposcopy for the detection of cervical cancer and precancerous lesions was evaluated. A total of 397 patients with confirmed cervical disease were enrolled between August 2020 and December 2021. According to the pathological diagnosis, the patients were divided into cervical intraepithelial neoplasia grade I (CIN I; n=153 cases), CIN II (n=101 cases), CIN III (n=86 cases) and cervical cancer (n=57 cases) groups. The HR-HPV-positive rate of the patients with different lesion types was compared, and the consistency of colposcopy and pathological examination results were assessed. For cervical cancer and precancerous lesions, the diagnostic value and efficacy of HR-HPV testing, colposcopy and combined HR-HPV testing and colposcopy examination were compared using pathological examination results as the gold standard. The results of the present study demonstrated that in patients with cervical cancer, the positive rate of HR-HPV (100.00%; n=57/57) was higher than that in patients with precancerous lesions, and the positive rate of HR-HPV in patients with CIN I type (36.60%, n=56/153) was lower than that in patients with CIN II (83.17%, n=84/101) and CIN III (82.56%, n=71/86) types (P<0.05). There was no significant difference in the HR-HPV-positive rate between patients with CIN II and CIN III (P>0.05). Cohen's κ coefficient for colposcopy examination and pathological examination of patients with cervical cancer and precancerous lesions was 0.622, the diagnostic accuracy was 90.43% (n=359/397), the positive predictive value was 65.57% (n=40/61), and the negative predictive value was 94.94% (n=319/336). Receiver operating characteristic curve analysis demonstrated that the area under the curve of the combined examination in the diagnosis of cervical cancer and precancerous lesions was 0.904, which was higher than that of colposcopy (0.820) or HR-HPV testing (0.802) alone (P<0.05). The results of the present study indicated that HR-HPV detection combined with colposcopy has diagnostic value for cervical cancer and precancerous lesions.

Computer-aided diagnosis of cervical dysplasia using colposcopic images

Background

computer-aided diagnosis of medical images is becoming more significant in intelligent medicine. Colposcopy-guided biopsy with pathological diagnosis is the gold standard in diagnosing CIN and invasive cervical cancer. However, it struggles with its low sensitivity in differentiating cancer/HSIL from LSIL/normal, particularly in areas with a lack of skilled colposcopists and access to adequate medical resources.

Methods

the model used the auto-segmented colposcopic images to extract color and texture features using the T-test method. It then augmented minority data using the SMOTE method to balance the skewed class distribution. Finally, it used an RBF-SVM to generate a preliminary output. The results, integrating the TCT, HPV tests, and age, were combined into a naïve Bayes classifier for cervical lesion diagnosis.

Results

the multimodal machine learning model achieved physician-level performance (sensitivity: 51.2%, specificity: 86.9%, accuracy: 81.8%), and it could be interpreted by feature extraction and visualization. With the aid of the model, colposcopists improved the sensitivity from 53.7% to 70.7% with an acceptable specificity of 81.1% and accuracy of 79.6%.

Conclusion

using a computer-aided diagnosis system, physicians could identify cancer/HSIL with greater sensitivity, which guided biopsy to take timely treatment.

Diagnostic value of colposcopy in patients with cytology-negative and HR-HPV-positive cervical lesions

PURPOSE

High-risk human papillomavirus (HR-HPV)-positive but cytology-negative cervical cancer screening results are not uncommon. This study aimed to investigate colposcopy's accuracy and diagnostic value in patients with cytology-negative HR-HPV-positive screening results.

METHODS

This retrospective study included patients with HR-HPV-positive cytology-negative screening results who underwent electronic colposcopy with acetic acid and multi-point cervical biopsy, HPV typing (24 HPV subtypes), and quantitative HPV detection.

RESULTS

Among 229 patients, 130 had chronic cervicitis, and 99 had cervical lesions (CIN1, n = 37; CIN2/3, n = 55; invasive carcinoma, n = 7). Using colposcopy as a reference, the cervical cytology false-negative rate was 43.2% (99/229). Colposcopy was more accurate in patients with HR-HPV16/18 or high viral loads. Multivariable analyses showed HPV viral load and childbearing history were the independent factors affecting the accuracy of colposcopy (P < 0.05).

CONCLUSION

Colposcopy in HR-HPV-positive cytology-negative patients has a moderate diagnostic accuracy. The type of cervical transformation zone and HPV viral load are independent factors affecting the accuracy of colposcopy-based diagnosis.

Cervical Cancer Screening Among Patients with Physical Disability

Background:

Pap smear has a central role in cervical cancer screening. Previous studies have found that female patients with disabilities are less likely to receive a Pap smear as recommended by guidelines. The aim of our study was to examine the association between physical disability and Pap smear receipt in Israel.

Methods:

This cross-sectional study was conducted using the electronic medical records of the second largest health care maintenance organization in Israel. All female patients during 2012–2017 aged 25–65 were identified. The exposure variable was physical disability, and the outcome variable was Pap smear receipt. We used logistic regression to control for covariates.

Results:

A total of 391,259 patients were eligible for this study, 6,720 (1.7%) with physical disability. 56.7% of patients with disabilities had received Pap smear compared to 63.3% of patients without disabilities, odds ratio (OR) 0.76, 95% confidence interval [CI] 0.72–0.80. When adjusting to sociodemographic and clinical covariates, patients with disabilities were less likely to receive Pap smear, adjusted OR 0.83, 95% CI 0.79–0.88. For all patients, older age, lower socioeconomic status, religious minorities, cardiovascular disease, type-2 diabetes mellitus, hypertension, smoking, and obesity were associated with lower odds of receipt of Pap smear. A history of nongynecologic oncologic disease was associated with increased odds of Pap smear receipt.

Conclusion:

Our study highlights the disparities between patients with and without physical disability with regard to screening for cervical cancer by receipt of Pap smear. Creating an appropriate practice with adequate access to patients with disability should be a focus for health care providers and policy makers.

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.

Screening test accuracy of portable devices that can be used to perform colposcopy for detecting CIN2+ in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Portable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited. The objective of this study was to systematically review the diagnostic test accuracy (DTA) of these devices for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+).

METHODS

In accordance with our protocol (Prospero CRD42018104286), we searched Embase, Medline and the Cochrane Controlled Register of Trials up to 9/2019. We included DTA studies, which investigated portable devices with moderate-to-high optical magnification (≥ 6×) for colposcopy, as described in the manual for Colposcopy and Treatment by the International Agency for Research on Cancer, with a histopathological reference standard. We used the QUADAS-2 tool to assess study quality. We examined results for sensitivity and specificity in paired forest plots, stratified by stages in the clinical pathway. We pooled estimates of test accuracy for the index test, used as an add-on to other tests, using a bivariate random-effect model.

RESULTS

We screened 1737 references and assessed 239 full-text articles for eligibility. Five single-gate DTA studies, including 2693 women, met the inclusion criteria. Studies evaluated two devices (Gynocular™ and Pocket) at different stages of the screening pathway. In three studies, which used the index test in an add-on capacity in 1273 women, we found a pooled sensitivity of 0.79 (95% CI 0.55-0.92) and specificity of 0.83 (95% CI 0.59-0.94). The main sources of bias were partial verification, incorporation and classification bias.

CONCLUSION

Few studies have evaluated portable devices able to perform colposcopy, so their accuracy for the detection of CIN2+ remains uncertain. Future studies should include patient-relevant and long-term outcomes, including missed cases, overtreatment, residual and recurrent disease. To meet the challenge of eliminating cervical cancer in LMIC, methods for visual assessment of the cervix need urgent redress.

Home-based HPV self-sampling assisted by a cloud-based electronic data system: Lessons learnt from a pilot community cervical cancer screening campaign in rural Ethiopia

Primary HPV testing and triage of HPV-positive women is an effective cervical cancer screening strategy. Such a multi-visit screening algorithm is also promising for community-based screening in resource-poor communities, provided a robust tracking system is in place.

A cervical cancer screening campaign was conducted in a rural community in Ethiopia. All women aged 25–65 years were offered genital self-sampling using the Evalyn Brush®. Samples were HPV-DNA-tested at a central laboratory. Key indicators were captured on tablet computers and linked by a cloud-based information system. HPV-positive women were examined at the local clinic using portable colposcopy, p16/Ki-67 dual stain cytology and biopsy examination. CIN2+ women were referred for LEEP to the referral hospital.

Of 749 enumerated age-eligible women 634 (85%, (95% CI 82–88)) consented to screening, 429 samples were adequate for HPV testing, giving a total testing coverage of 57% (95% CI 53–62). The hrHPV prevalence was 14% (95% CI 5–22), 72% (95% CI 60–84) attended the clinic for a triage examination. Home-based HPV-DNA self-sampling and clinic-based triage assisted by cloud-based information technology is feasible in rural Ethiopia. Key components of such strategy are broad community awareness, high competency of community workers, and establishment of an adequate self-sampling and HPV-DNA testing platform.

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.

An on-going study of three different cervical cancer screening strategies based on primary healthcare facilities in Beijing China

BACKGROUND

To evaluate and compare the results of three different cervical cancer screening strategies including cytology screening, HR-HPV screening which taking HR-HPV testing as primary test and co-testing which taking both tests at the same time, then provide evidence to explore whether the cervical cancer screening can be conducted in community healthcare centers in Beijing.

METHODS

182,119 women aged between 35 and 64, who were screened in the primary healthcare facilities of nine districts in Beijing from January 2014 to March 2015, were enrolled in this study. Cytology screening was performed in participants during January 2014 and December 2014 as a conventional arm. HR-HPV screening strategy and co-testing were randomly allocated to participants on districts level as experimental arm 1 and 2 during January 2015 and March 2015. Cervical Intraepithelial Neoplasia grade 2 or worse (CIN 2+) was defined as endpoint. The screening results and costs to detect a case of three strategies were calculated.

RESULTS

The positivity rate, colposcopy referral rate and biopsy referral rate of co-testing were 8.46%, 6.36% and 4.65% respectively, which were all significantly higher than the other two screening strategies. The detection rate of CIN 2+ by co-testing was 5.06‰ and was much more than the other two screening strategies, while the HR-HPV screening had the highest PPV of 14.40%. The HR-HPV screening ignores some lesion which can be found by co-testing. Co-testing refers a woman to colposcopy with a positive screening result at the least cost, but it costs the most to detect a CIN 2+ case.

CONCLUSIONS

To detect more cases of CIN 2+, co-testing performs better although with the most cost. And the primary healthcare facilities in Beijing have the capability to carry out the cervical cancer screen programs and prompts women with positive screen results to the hospital.