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Ngalla C, Didymus J, Manjuh F, Nwufor M, Nkfusai J, Elit L, Fokom Domgue J. Challenges faced in managing cervical cancer patients who present post-operatively with more advanced disease in LMICs: Case studies from Cameroon. Gynecol Oncol Rep 2024; 55:101485. [PMID: 39247488 PMCID: PMC11378922 DOI: 10.1016/j.gore.2024.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/30/2024] [Accepted: 08/09/2024] [Indexed: 09/10/2024] Open
Abstract
Cameroon is a low-and-middle income country (LMIC) with one of the highest incidence and mortality from cervical cancer in Africa. In this Central African country where the prevalence of human immunodeficiency virus (HIV) is high and the screening coverage is low, cervical cancer is the most deadly and the second most common cancer among women. Notwithstanding the growing burden of cervical cancer in Cameroon, most patients - often of lower socioeconomic status - continue to encounter multi-level barriers to timely and adequate care. These include the lack of physical and financial access to healthcare facilities, limited quality pathology, imaging and treatment services, ignorance of disease by the population, shortage of a well-trained oncology workfroce, which result in significant delays in gaining access to screening, diagnosis, treatment and care. This paper presents 3 cases of patients with advanced cervical cancer who had surgery (hysterectomy) as primary treatment, without appropriate post-surgical investigation to further specify disease stage, persistence of residual disease, and need for adjuvant chemoradiation. Pathology services and diagnostic imaging procedures remain scarce and underused in LMIC countries like Cameroon. Healthcare professionals involved in patient care lack adequate knowledge, skills and collaborative strategy to properly navigate these patients. To address these challenges, the health system should be reinforced with adequate infrastructures, sustainable funding should be secured to enhance universal health coverage and promote cancer prevention and control programs, multidisciplinary teams and coordination of care among providers should be improved, and relevant health indicators should be put in place to better monitor the quality of care delivered to patients who are mostly vulnerable and uninformed.
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Affiliation(s)
- Calvin Ngalla
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
| | - Jaff Didymus
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
| | - Florence Manjuh
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
| | - Marius Nwufor
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
| | | | - Laure Elit
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
| | - Joel Fokom Domgue
- Women's Health Program, Cameroon Baptist Convention Health Services, Cameroon
- Centre Inter-Etats d'Enseignement Supérieur en Santé Publique d'Afrique Centrale, Brazzaville, Congo
- Departments of Obstetrics and Gynecology & Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon
- Department of Gynecologic Oncology and Reproductive Medicine, and Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Akgor U, Ozgul N, Gunes AC, Turkyılmaz M, Gultekin M. Evaluation of Endocervical Curettage in Colposcopy in the Turkish Cervical Cancer Screening Program. J Clin Med 2024; 13:4417. [PMID: 39124684 PMCID: PMC11313522 DOI: 10.3390/jcm13154417] [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: 07/01/2024] [Revised: 07/21/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: To investigate the risk factors for CIN2+ lesions (cervical intraepithelial neoplasia 3 or worse) in endocervical curettage (ECC) and to evaluate the relationship between the addition of ECC to punch biopsy in terms of the yield of CIN2+ lesions. Methods: Between February 2018 and 2019, data on colposcopy results from 11,944 patients were gathered from the Cancer Department of the Turkish Ministry of Health across the country. A total of 6370 women whom were referred to colposcopy were included in this study. Risk factors were identified using both univariate and multivariate logistic analyses. Results: The median age was 42 years old (range, 30-65). ASC-H (atypical squamous cells-suggestive of high-grade squamous intraepithelial lesion)/HSIL (high-grade intraepithelial lesion) cytology (OR 7.648 95% CI (3.933-14.871)) and HPV (human papillomavirus)-16/18 infection (OR 2.541 95% CI (1.788-3.611)) were identified as risk factors for having CIN2+ lesions. CIN2+ diagnostic yield by ECC is only 1.2% all patients. CIN2+ diagnostic yield by punch biopsy and ECC are 9.7% and 6% of patients, respectively. A higher CIN2+ yield by ECC was observed with increasing age. Among cytology groups, ASC-H/HSIL has highest CIN2+ yield by ECC. Finally, in patients with incomplete visualization of the squamocolumnar junction (SCJ), ECC yields approximately twice as many CIN2+ lesions. Conclusions: ECC should be considered in cases of advanced patient age and in situations where the SCJ is not routinely visualized. In addition, evaluation of the endocervical canal is necessary in HPV-positive cases infected with HPV-16/18 types and in cases infected with HPV of any type but with cytological abnormalities.
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Affiliation(s)
- Utku Akgor
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Nejat Ozgul
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Ali Can Gunes
- Department of Obstetrics and Gynecology, Mamak State Hospital, Ankara 06320, Turkey;
| | - Murat Turkyılmaz
- Department of Cancer Control, Turkish Ministry of Health, Public Health Institute, Ankara 06200, Turkey
| | - Murat Gultekin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
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Lu Y, Wu H, Fu K, Shen Y, Li L, Liao Z, Liu Y, Kang Y, Zhang Y. PAX1 methylation as a robust predictor: developing and validating a nomogram for assessing endocervical curettage (ECC) necessity in human papillomavirus16/18-positive women undergoing colposcopy. Clin Epigenetics 2024; 16:77. [PMID: 38849868 PMCID: PMC11157736 DOI: 10.1186/s13148-024-01691-1] [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: 02/27/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
OBJECTIVE The major challenge in routine endocervical curettage (ECC) among Human Papillomavirus (HPV) 16/18-positive patients is that only a small fraction benefit. Nevertheless, current reported models often overestimate the validity and necessity of ECC, making it difficult to improve benefits for patients. This research hypothesized that assessing paired boxed gene 1 methylation levels (PAX1m) and clinical characteristics could enhance the predictive accuracy of detecting additional high-grade squamous intraepithelial lesions or worse (HSIL +) through ECC that were not identified by colposcopy-directed biopsy (CDB). METHODS Data from 134 women with HPV16/18 positivity undergoing CDB and ECC between April 2018 and April 2022 were collected and analyzed. Quantitative methylation-specific polymerase chain reaction (qMSP) was utilized to measure PAX1m, expressed as ΔCp. Univariate and multivariate regression analyses were conducted to screen variables and select predictive factors. A nomogram was constructed using multivariate logistic regression to predict additional HSIL + detected by ECC. The discrimination, calibration, and clinical utility of the nomogram were evaluated using receiver operating characteristic curves (ROC) and the calibration plot. RESULTS Age (odds ratio [OR], 5.654; 95% confidence interval [CI], 1.131-37.700), cytology (OR, 24.978; 95% CI, 3.085-540.236), and PAX1 methylation levels by grade (PAX1m grade) (OR, 7.801; 95% CI, 1.548-44.828) were independent predictive factors for additional detection of HSIL + by ECC. In HPV16/18-positive women, the likelihood of additional detection of HSIL + through ECC increased with the severity of cytological abnormalities, peaking at 43.8% for high-grade cytological lesions. Moreover, when cytological findings indicated low-grade lesions, PAX1 methylation levels were positively correlated with the additional detection of HSIL + by ECC (P value < 0.001). A nomogram prediction model was developed (area under curve (AUC) = 0.946; 95% CI, 0.901-0.991), demonstrating high sensitivity (90.9%) and specificity (90.5%) at the optimal cutoff point of 107. Calibration analysis confirmed the model's strong agreement between predicted and observed probabilities. CONCLUSION The clinical nomogram presented promising predictive performance for the additional detection of HSIL + through ECC among women with HPV16/18 infection. PAX1 methylation level could serve as a valuable tool in guiding individualized clinical decisions regarding ECC for patients with HPV 16/18 infection, particularly in cases of low-grade cytological findings.
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Affiliation(s)
- Yingnan Lu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Haiyue Wu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Kun Fu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - YuFei Shen
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Lucia Li
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Zexi Liao
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yingzhen Liu
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Yanan Kang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
| | - Yu Zhang
- Department of Gynecology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
- Gynecological Oncology Research and Engineering Center of Hunan Province, 87 Xiangya Road, Changsha, 410008, Hunan, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
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Li X, Zhao Y, Xiang F, Zhang X, Chen Z, Zhang M, Kang X, Wu R. Evaluation of the diagnostic performance of colposcopy in the detection of cervical high-grade squamous intraepithelial lesions among women with transformation zone type 3. BMC Cancer 2024; 24:381. [PMID: 38528547 DOI: 10.1186/s12885-024-12156-2] [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: 09/26/2023] [Accepted: 03/20/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Inaccurate colposcopy diagnosis may lead to inappropriate management and increase the incidence of cervical cancer. This study aimed to evaluate the diagnostic accuracy of colposcopy in the detection of histologic cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in women with transformation zone type 3 (TZ3). METHODS Records from 764 patients with TZ3 who underwent colposcopy-directed biopsy and/or endocervical curettage in Putuo Hospital China between February 2020 and March 2023 were retrospectively collected. Colposcopy was carried out based on 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) and Colposcopy nomenclature. The diagnostic performance of colposcopy for identifying CIN2 + was evaluated compared with biopsies. The Kappa and McNemar tests were used to perform statistical analyses. RESULTS Among the study population, 11.0% had pathologic CIN2+. The relative sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of colposcopy for histologic CIN2 + were 51.2%, 96.5%, 64.2% and 94.1%, respectively. The senior colposcopists (80.6%) had a higher colposcopic accuracy to diagnose histologic CIN2 + than junior colposcopists (68.6%). In subgroup analyses, age group ≥ 60 years (70.3%) showed lowest diagnostic accuracy when compared with age groups of < 45 years (84.4%) and 45-59 years (74.9%). CONCLUSION Our findings suggest an increased risk of diagnostic inaccuracy of colposcopy in identifying CIN2 + in those ≥ 60 years of age with TZ3, and the accuracy of colposcopy is required to be further improved.
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Affiliation(s)
- Xiaoxiao Li
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yunzhi Zhao
- Department of Obstetrics and Gynecology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fenfen Xiang
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xinpei Zhang
- Department of Obstetrics and Gynecology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zixi Chen
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mengzhe Zhang
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiangdong Kang
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Rong Wu
- Department of Laboratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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Wittenborn J, Flasshove EM, Kupec T, Najjari L, Stickeler E, Maurer J. A Glimmer of Hope for Patients with a T3 Transformation Zone: miRNAs Are Potential Biomarkers for Cervical Dysplasia. Diagnostics (Basel) 2023; 13:3599. [PMID: 38132183 PMCID: PMC10742976 DOI: 10.3390/diagnostics13243599] [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: 10/27/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND This pilot study assesses the potential use of miRNAs in the triage of colposcopy patients with type 3 (nonvisible) cervical transformation zone (TZ). Type 3 TZ is a constitutional finding associated with many problems and controversies in colposcopy patient management. Here, we present miRNAs as a potential biomarker for the detection of CIN3 in these cases. MATERIALS AND METHODS Cervical mucosa samples (CMS) were collected from patients presenting with T3 transformation zone during routine workup using the Cytobrush. Depending on the histological and cytological result, as well as the result of the routinely performed HPV PCR, patients were divided into three groups: patients with a high-grade intraepithelial lesion (CIN3) and a positive high-risk HPV test (CIN3 group), patients without an intraepithelial lesion and a positive high-risk HPV test (HPV group), and healthy controls (N = no intraepithelial lesion and negative HPV test). The cervical mucus samples included in the study were tested for their expression levels of distinct miRNAs using qPCR. RESULTS All investigated miRNAs were consistently detectable in every sample. The CMSs of histologically graded CIN 3 showed consistently high expression levels of all eight miRNAs, whereas the CMSs from healthy patients (N) show generally lower expression levels. However, CMSs from patients of the HPV group represented a very heterogeneous group. CONCLUSIONS The data presented here can provide a solid basis for future research into a triage test for patients with a T3 transformation zone on the basis of commonly used clinical equipment.
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Affiliation(s)
- Julia Wittenborn
- Department of Obstetrics and Gynecology, University Hospital of the RWTH Aachen, 52074 Aachen, Germany (J.M.)
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Effah K, Tekpor E, Wormenor CM, Essel NOM. Transformation zone types: a call for review of the IFCPC terminology to embrace practice in low-resource settings. Ecancermedicalscience 2023; 17:1612. [PMID: 38414959 PMCID: PMC10898880 DOI: 10.3332/ecancer.2023.1612] [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: 07/17/2023] [Indexed: 02/29/2024] Open
Abstract
Most cervical cancers develop in the transformation zone (TZ). Type 3 TZs, where the full circumference of the squamocolumnar junction (SCJ) is not visible pose problems during cervical screening with visual inspection methods, as (pre)cancerous lesions may be missed. Several practical strategies can be implemented to convert type 3 TZs into TZ 1 or TZ 2, including the use of an endocervical speculum or hygroscopic cervical dilators, opening the vaginal speculum more widely, skillful use of cotton-tipped applicators, performing colposcopy in midcycle, and use of oral or vaginal misoprostol and estrogen to 'ripen' the cervix. With the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) terminology, settings with better resources to manipulate the cervix for a better view of the endocervical canal may assign patients to different categories from those in low-resource settings during a colposcopic examination. Here, we propose a colposcopic revision to the current IFCPC classification by segregating TZ 2 according to the extent of endocervical involvement and TZ 3 according to whether any attempt is made to open the endocervical canal, if such attempt(s) were successful, and the extent to which the practitioner can visualise parts of the uterine cervix beyond the border of the SCJ in the endocervical canal. In this proposed reclassification, TZ 2A has no part of the SCJ extending beyond 5 mm into the endocervical canal, whereas TZ 2B has part or all of the SCJ extending beyond 5 mm into the endocervical canal. TZ 3 is further subclassified into TZ 3A if the practitioner does not attempt to open the endocervical canal or the endocervical canal is opened, but not beyond 5 mm and TZ 3B if the full circumference cannot be visualised after opening the endocervical canal beyond 5 mm. We believe this revision will improve and better standardise the classification of TZ types, with huge implications for practice in low-resource settings, due to limited options for referral and treatment, to reduce the risk of missed cervical cancers and suboptimal treatment resulting from ablating lesions that extend too far into the endocervical canal.
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Affiliation(s)
- Kofi Effah
- Cervical Cancer Prevention and Training Centre (CCPTC), Catholic Hospital, Battor, PO Box 2, Battor, via Sogakope, Volta Region, Ghana
- https://orcid.org/0000-0003-1216-2296
| | - Ethel Tekpor
- Cervical Cancer Prevention and Training Centre (CCPTC), Catholic Hospital, Battor, PO Box 2, Battor, via Sogakope, Volta Region, Ghana
| | - Comfort Mawusi Wormenor
- Cervical Cancer Prevention and Training Centre (CCPTC), Catholic Hospital, Battor, PO Box 2, Battor, via Sogakope, Volta Region, Ghana
| | - Nana Owusu Mensah Essel
- Department of Emergency Medicine, College of Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, 730 University Terrace, Edmonton, AB T6G 2T4, Canada
- https://orcid.org/0000-0001-5494-5411
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