Overtreatment and Cost-Effectiveness of the See-and-Treat Strategy for Managing Cervical Precancer

Identification of a novel hypermethylation marker, ZSCAN18, and construction of a diagnostic model in cervical cancer

PURPOSE

Cervical cancer (CC), a common female malignancy, has been linked to alterations in DNA methylation. This study employed an integrated "dry-wet lab" strategy combining bioinformatics, machine learning, and experimental validation to identify novel methylation biomarkers for CC.

METHODS

Methylome and transcriptome data from the TCGA and GEO cohorts (n=349 discovery, n=414 validation) were analyzed to identify differentially methylated CpGs. The top candidates were validated by pyrosequencing, methylation-specific PCR, and quantitative assays. Diagnostic models were developed, and functional studies were performed for the target markers.

RESULTS

Eighteen differentially methylated CpGs were identified, with five top candidates (three in the ZSCAN18 promoter) showing diagnostic potential. ZSCAN18 promoter methylation levels and positivity rates were significantly greater in CC tissues than in normal tissues (p<0.05), reaching 77.8% (21/27) in ThinPrep cytology test (TCT) samples. The ridge regression diagnostic model achieved an AUC of 0.9421 in the validation cohort. Similarly, ZSCAN18 overexpression suppressed CC cell proliferation (p<0.05).

CONCLUSIONS

This study established a rapid, effective and systematic systemic research strategy to screen novel methylation markers for CC. ZSCAN18 promoter methylation correlates with cervical lesion severity, and the diagnostic model enhances the diagnostic ability. These findings highlight the dual role of ZSCAN18 as a diagnostic marker and potential therapeutic target.

Factors associated with willingness to perform expedited excisional treatment for patients at high risk for cervical precancer

Background

The 2019 ASCCP Risk-Based Management Consensus Guidelines prefer expedited treatment, defined as proceeding to excisional treatment without first performing colposcopic biopsy, for patients with screening results indicating a high risk of cervical precancer. In this mixed methods study, we explored clinician attitudes toward expedited treatment.

Methods

In 2021, a national sample of 671 clinicians who performed colposcopy completed surveys; a subset (n = 41) of clinicians who performed colposcopy and/or directed patient treatment completed qualitative interviews.

Results

Among 671 colposcopists, 25.7 % were currently performing expedited treatment, 50.8% were not currently using expedited treatment but were willing to adopt this change, and 23.6% were not willing to perform expedited treatment. Binomial regression analyses indicated that internal medicine and family medicine clinicians (compared to Obstetrician-Gynecologists), and those practicing in academic medal centers (compared to private practice) had higher odds of currently performing expedited treatment; internal and family medicine clinicians also reported higher odds of being willing to adopt this change. Qualitative interviews highlighted benefits including improved cancer prevention among older patients, reduced loss to follow-up, reduction of time and expense for patients, and allowing shared decision-making. Concerns expressed related to future pregnancy complications, lack of available excisional treatment services (e.g., LEEP), patient preference, avoiding over- and under-treatment, and using biopsy results to plan excisional procedures.

Conclusions

Approximately 25 % of colposcopists are currently performing expedited treatment, and an additional 50 % would be willing to adopt this practice for high-risk patients. Improving access to expedited treatment for appropriate patients could improve cervical cancer prevention.

Prevention Strategies and Early Diagnosis of Cervical Cancer: Current State and Prospects

Cervical cancer ranks third among all new cancer cases and causes of cancer deaths in females. The paper provides an overview of cervical cancer prevention strategies employed in different regions, with incidence and mortality rates ranging from high to low. It assesses the effectiveness of approaches proposed by national healthcare systems by analysing data published in the National Library of Medicine (Pubmed) since 2018 featuring the following keywords: "cervical cancer prevention", "cervical cancer screening", "barriers to cervical cancer prevention", "premalignant cervical lesions" and "current strategies". WHO's 90-70-90 global strategy for cervical cancer prevention and early screening has proven effective in different countries in both mathematical models and clinical practice. The data analysis carried out within this study identified promising approaches to cervical cancer screening and prevention, which can further enhance the effectiveness of the existing WHO strategy and national healthcare systems. One such approach is the application of AI technologies for detecting precancerous cervical lesions and choosing treatment strategies. As such studies show, the use of AI can not only increase detection accuracy but also ease the burden on primary care.

Mailed self-sample HPV testing kits to improve cervical cancer screening in a safety net health system: protocol for a hybrid effectiveness-implementation randomized controlled trial

BACKGROUND

Almost 20% of U.S. women remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation.

METHODS/DESIGN

The Prospective Evaluation of Self-Testing to Increase Screening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2268 participants randomized to telephone recall (enhanced usual care, n = 756), telephone recall with mailed self-sample HPV testing kit (intervention, n = 756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n = 756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness.

DISCUSSION

Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform screening strategies to ultimately realize the global goal of eliminating cervical cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898167 . Registered on 01 April 2019.

TRIAL STATUS

Study start data: February 13, 2020. Recruitment status: Enrolling by invitation. Estimated primary completion date: February 15, 2023. Estimated study completion date: May 31, 2024. Protocol version 1.6 (February 25, 2020).

Comparative performance evaluation of different HPV tests and triaging strategies using self-samples and feasibility assessment of thermal ablation in 'colposcopy and treat' approach: A population-based study in rural China

Human papillomavirus (HPV) test, self-sampling and thermal ablation for cervical intraepithelial neoplasia (CIN) have been developed separately to increase screening coverage and treatment compliance of cervical cancer screening programmes. A large-scale study in rural China screened 9,526 women with their combinations to explore the optimal cervical cancer-screening cascade in the real-world. Participants received careHPV and polymerase chain reaction (PCR) HPV tests on self-collected samples. Women positive on either HPV test underwent colposcopy, biopsy and thermal ablation in a single visit. Samples positive on either HPV test were retested for genotyping. Absolute and relative performance of HPV tests, triage strategies, 'colposcopy and thermal ablation' approach were statistically evaluated. PCR HPV test detected 33.3% more CIN grade two or worse (CIN2+) at a cost of 28.1% more colposcopies compared to careHPV. Sensitivities of PCR HPV and careHPV tests to detect CIN2+ were 96.7 and 72.5%. Specificities for the same disease outcome were 82.1 and 86.0%. Triaging HPV-positive women with HPV16/18 genotyping considerably improved the positive predictive value for CIN2+ (4.8-5.0 to 18.2-19.2%). Ninety-six women positive on HPV and having abnormal colposcopy were eligible for thermal ablation and all accepted same-day treatment, contributing to 64.6% being treated appropriately (CIN1+ on histopathology), which reached up to 84.8% among women positive on HPV 16/18 triage. No serious side-effects/complications were reported. The combination of PCR HPV test followed by HPV 16/18 triaging on self-collected samples and colposcopy of triage positive women followed by immediate thermal ablation might be the appropriate screening cascade for rural China.

Self-Sampling as a Plausible Alternative to Screen Cervical Cancer Precursor Lesions in a Population with Low Adherence to Screening: A Systematic Review

BACKGROUND

Cervical cancer is the fourth most common cancer in the world. A raised incidence and mortality parallel a low participation rate in screening, namely screening in poor countries and among specific populations of developed countries. Cervical or vaginal self-sampling may increase adherence to screening due to its low costs and elevated sensibility and specificity. Our main goal was to compare self-sampling with physician sampling and to evaluate the participation rate of women formerly non-adherent to cervical cancer screening.

STUDY DESIGN

We identified relevant studies from PubMed. Studies were eligible for inclusion if they fulfilled the following criteria: women aged between 16 and 80 years, poor and developed countries that use self-sampling, women with a low participation rate in screening and studies published since 2013. After fully reading the articles, data were extracted to an Excel sheet to -display all relevant information in an organized manner. -Results: We identified 18 studies, which altogether enrolled 22,118 women. Self-sampling and physician sampling are quite similar regarding the HPV detection rate. Women have a low participation rate mainly because of limited access to health services, religious and culture beliefs, and lack of time due to several demanding tasks in daily life. Self-sampling shows a significant increase in acceptability and preference compared to physician sampling.

CONCLUSION

Self-sampling is a reliable method to involve women in opportunistic or organized screening programs for cervical cancer prevention.

Factors Related to Overtreatment in the See-and-Treat Approach: A Retrospective Multicentric Observational Study

OBJECTIVE

The aim of the study was to evaluate the association between colposcopic features, age, menopausal status, and overtreatment in women subjected to "see-and-treat" approach, to identify subgroups of patients in which this approach could be more appropriate.

MATERIALS AND METHODS

Retrospective multicentric cohort study conducted on women older than 25 years, with a high-grade squamous cytological report and a visible squamocolumnar junction, in which colposcopy and the excisional procedure were performed at the same time without a previous cervical biopsy (see and treat). Overtreatment was defined as histopathological finding of cervical intraepithelial lesion grade 1 or normal tissue.

RESULTS

Among the 254 included patients, the overall overtreatment rate was 12.6%, whereas in women with a grade 2 colposcopy, it was 3.2% and, in women with grade 1 colposcopy, it was 22.0%. Among the considered factors (age, menopause, and grade 1 colposcopy), only a positive association with overtreatment and grade 1 colposcopy emerged (odds ratio = 8.70, 95% CI = 2.95-25.62, p < .001).

CONCLUSIONS

See and treat may be appropriate in women older than 25 years with a visible squamocolumnar junction and a high-grade squamous cervical cytology. Patients need to be informed about the higher risk of overtreatment in case of a grade 1 colposcopic impression, which however may still be considered acceptable. Patient's age and menopausal status should not influence the decision to propose a see-and-treat approach.