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Desai KT, Hansen N, Rodriguez AC, Befano B, Egemen D, Gage JC, Wentzensen N, Lopez C, Jeronimo J, de Sanjose S, Schiffman M. Squamocolumnar junction visibility, age, and implications for cervical cancer screening programs. Prev Med 2024; 180:107881. [PMID: 38286273 PMCID: PMC10922959 DOI: 10.1016/j.ypmed.2024.107881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 01/31/2024]
Abstract
Visual assessment is currently used for primary screening or triage of screen-positive individuals in cervical cancer screening programs. Most guidelines recommend screening and triage up to at least age 65 years old. We examined cervical images from participants in three National Cancer Institute funded cervical cancer screening studies: ALTS (2864 participants recruited between 1996 to 1998) in the United States (US), NHS (7548 in 1993) in Costa Rica, and the Biopsy study (684 between 2009 to 2012) in the US. Specifically, we assessed the visibility of the squamocolumnar junction (SCJ), which is the susceptible zone for precancer/cancer by age, as reported by colposcopist reviewers either at examination or review of cervical images. The visibility of the SCJ declined substantially with age: by the late 40s the majority of people screened had at most partially visible SCJ. On longitudinal analysis, the change in SCJ visibility from visible to not visible was largest for participants from ages 40-44 in ALTS and 50-54 in NHS. Of note, in the Biopsy study, the live colposcopic exam resulted in significantly higher SCJ visibility as compared to review of static images (Weighted kappa 0.27 (95% Confidence Interval: 0.21, 0.33), Asymmetry chi-square P-value<0.001). Lack of SCJ visibility leads to increased difficulty in diagnosis and management of cervical precancers. Therefore, cervical cancer screening programs reliant on visual assessment might consider lowering the upper age limit for screening if there are not adequately trained personnel and equipment to evaluate and manage participants with inadequately visible SCJ.
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Affiliation(s)
- Kanan T Desai
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States; Internal Medicine Residency, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, United States.
| | - Natasha Hansen
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Ana-Cecilia Rodriguez
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Brian Befano
- University of Washington, Seattle, United States; Information Management Services, MD, United States
| | - Didem Egemen
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Julia C Gage
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Nicolas Wentzensen
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | | | - Jose Jeronimo
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
| | - Silvia de Sanjose
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States; ISGlobal Barcelona, Spain
| | - Mark Schiffman
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, United States
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de Sanjosé S, Perkins RB, Campos N, Inturrisi F, Egemen D, Befano B, Rodriguez AC, Jerónimo J, Cheung LC, Desai K, Han P, Novetsky AP, Ukwuani A, Marcus J, Ahmed SR, Wentzensen N, Kalpathy-Cramer J, Schiffman M. Design of the HPV-automated visual evaluation (PAVE) study: Validating a novel cervical screening strategy. eLife 2024; 12:RP91469. [PMID: 38224340 PMCID: PMC10945624 DOI: 10.7554/elife.91469] [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] [Indexed: 01/16/2024] Open
Abstract
Background The HPV-automated visual evaluation (PAVE) Study is an extensive, multinational initiative designed to advance cervical cancer prevention in resource-constrained regions. Cervical cancer disproportionally affects regions with limited access to preventive measures. PAVE aims to assess a novel screening-triage-treatment strategy integrating self-sampled HPV testing, deep-learning-based automated visual evaluation (AVE), and targeted therapies. Methods Phase 1 efficacy involves screening up to 100,000 women aged 25-49 across nine countries, using self-collected vaginal samples for hierarchical HPV evaluation: HPV16, else HPV18/45, else HPV31/33/35/52/58, else HPV39/51/56/59/68 else negative. HPV-positive individuals undergo further evaluation, including pelvic exams, cervical imaging, and biopsies. AVE algorithms analyze images, assigning risk scores for precancer, validated against histologic high-grade precancer. Phase 1, however, does not integrate AVE results into patient management, contrasting them with local standard care.Phase 2 effectiveness focuses on deploying AVE software and HPV genotype data in real-time clinical decision-making, evaluating feasibility, acceptability, cost-effectiveness, and health communication of the PAVE strategy in practice. Results Currently, sites have commenced fieldwork, and conclusive results are pending. Conclusions The study aspires to validate a screen-triage-treat protocol utilizing innovative biomarkers to deliver an accurate, feasible, and cost-effective strategy for cervical cancer prevention in resource-limited areas. Should the study validate PAVE, its broader implementation could be recommended, potentially expanding cervical cancer prevention worldwide. Funding The consortial sites are responsible for their own study costs. Research equipment and supplies, and the NCI-affiliated staff are funded by the National Cancer Institute Intramural Research Program including supplemental funding from the Cancer Cures Moonshot Initiative. No commercial support was obtained. Brian Befano was supported by NCI/ NIH under Grant T32CA09168.
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Affiliation(s)
- Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
- ISGlobalBarcelonaSpain
| | - Rebecca B Perkins
- University Chobanian and Avedisian School of Medicine/Boston Medical CenterBostonUnited States
| | - Nicole Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Federica Inturrisi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Brian Befano
- Information Management Services IncCalvertonUnited States
- Department of Epidemiology, University of Washington School of Public HealthSeattleUnited States
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jose Jerónimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Li C Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Kanan Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Paul Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Akiva P Novetsky
- Westchester Medical Center/New York Medical CollegeValhallaUnited States
| | - Abigail Ukwuani
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jenna Marcus
- Feinberg School of Medicine at Northwestern UniversityChicagoUnited States
| | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General HospitalBostonUnited States
- Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard UniversityCambridgeUnited States
- Massachusetts Institute of TechnologyCambridgeUnited States
- Geisel School of Medicine at Dartmouth, Dartmouth CollegeHanoverUnited States
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General HospitalBostonUnited States
- University of Colorado Anschutz Medical CampusAuroraUnited States
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of HealthRockvilleUnited States
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Desai KT, de Sanjosé S, Schiffman M. Treatment of Cervical Precancers is the Major Remaining Challenge in Cervical Screening Research. Cancer Prev Res (Phila) 2023; 16:649-651. [PMID: 38037384 DOI: 10.1158/1940-6207.capr-23-0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023]
Abstract
Deepening understanding of cervical cancer pathogenesis has yielded one-dose prophylactic human papillomavirus (HPV) vaccines and accurate HPV-based cervical screening tests. Knowing the heterogeneous carcinogenic potential of the individual high-risk HPV types permits prioritization of vaccination and screening strategies. However, "correct" (i.e., safe and effective) treatment of women found to have precancer is still undefined, forcing reliance on one or more rounds of untargeted destructive/excisional treatment. Both over-treatment and under-treatment are common results. Until safe and effective anti-HPV therapies are invented, defining optimal destructive/excisional treatment of precancer remains a fundamental and under-researched challenge, especially in resource-constrained settings. See related article by King et al., p. 681.
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de Sanjosé S, Perkins RB, Campos NG, Inturrisi F, Egemen D, Befano B, Rodriguez AC, Jerónimo J, Cheung LC, Desai K, Han P, Novetsky AP, Ukwuani A, Marcus J, Ahmed SR, Wentzensen N, Kalpathy-Cramer J, Schiffman M. Design of the HPV-Automated Visual Evaluation (PAVE) Study: Validating a Novel Cervical Screening Strategy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.30.23294826. [PMID: 37693492 PMCID: PMC10491363 DOI: 10.1101/2023.08.30.23294826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Objective To describe the HPV-Automated Visual Evaluation (PAVE) Study, an international, multi-centric study designed to evaluate a novel cervical screen-triage-treat strategy for resource-limited settings as part of a global strategy to reduce cervical cancer burden. The PAVE strategy involves: 1) screening with self-sampled HPV testing; 2) triage of HPV-positive participants with a combination of extended genotyping and visual evaluation of the cervix assisted by deep-learning-based automated visual evaluation (AVE); and 3) treatment with thermal ablation or excision (Large Loop Excision of the Transformation Zone). The PAVE study has two phases: efficacy (2023-2024) and effectiveness (planned to begin in 2024-2025). The efficacy phase aims to refine and validate the screen-triage portion of the protocol. The effectiveness phase will examine acceptability and feasibility of the PAVE strategy into clinical practice, cost-effectiveness, and health communication within the PAVE sites. Study design Phase 1 Efficacy: Around 100,000 nonpregnant women, aged 25-49 years, without prior hysterectomy, and irrespective of HIV status, are being screened at nine study sites in resource-limited settings. Eligible and consenting participants perform self-collection of vaginal specimens for HPV testing using a FLOQSwab (Copan). Swabs are transported dry and undergo testing for HPV using a newly-redesigned isothermal DNA amplification HPV test (ScreenFire HPV RS), which has been designed to provide HPV genotyping by hierarchical risk groups: HPV16, else HPV18/45, else HPV31/33/35/52/58, else HPV39/51/56/59/68. HPV-negative individuals are considered negative for precancer/cancer and do not undergo further testing. HPV-positive individuals undergo pelvic examination with collection of cervical images and targeted biopsies of all acetowhite areas or endocervical sampling in the absence of visible lesions. Accuracy of histology diagnosis is evaluated across all sites. Cervical images are used to refine a deep learning AVE algorithm that classifies images as normal, indeterminate, or precancer+. AVE classifications are validated against the histologic endpoint of high-grade precancer determined by biopsy. The combination of HPV genotype and AVE classification is used to generate a risk score that corresponds to the risk of precancer (lower, medium, high, highest). During the efficacy phase, clinicians and patients within the PAVE sites will receive HPV testing results but not AVE results or risk scores. Treatment during the efficacy phase will be performed per local standard of care: positive Visual Inspection with Acetic Acid impression, high-grade colposcopic impression or CIN2+ on colposcopic biopsy, HPV positivity, or HPV 16,18/45 positivity. Follow up of triage negative patients and post treatment will follow standard of care protocols. The sensitivity of the PAVE strategy for detection of precancer will be compared to current SOC at a given level of specificity.Phase 2 Effectiveness: The AVE software will be downloaded to the new dedicated image analysis and thermal ablation devices (Liger Iris) into which the HPV genotype information can be entered to provide risk HPV-AVE risk scores for precancer to clinicians in real time. The effectiveness phase will examine clinician use of the PAVE strategy in practice, including feasibility and acceptability for clinicians and patients, cost-effectiveness, and health communication within the PAVE sites. Conclusion The goal of the PAVE study is to validate a screen-triage-treat protocol using novel biomarkers to provide an accurate, feasible, cost-effective strategy for cervical cancer prevention in resource-limited settings. If validated, implementation of PAVE at larger scale can be encouraged. Funding The consortial sites are responsible for their own study costs. Research equipment and supplies, and the NCI-affiliated staff are funded by the National Cancer Institute Intramural Research Program including supplemental funding from the Cancer Cures Moonshot Initiative. No commercial support was obtained. Brian Befano was supported by NCI/NIH under Grant T32CA09168. Date of protocol latest review: September 24 th 2023.
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Parham GP, Egemen D, Befano B, Mwanahamuntu MH, Rodriguez AC, Antani S, Chisele S, Munalula MK, Kaunga F, Musonda F, Malyangu E, Shibemba AL, de Sanjose S, Schiffman M, Sahasrabuddhe VV. Validation in Zambia of a cervical screening strategy including HPV genotyping and artificial intelligence (AI)-based automated visual evaluation. Infect Agent Cancer 2023; 18:61. [PMID: 37845724 PMCID: PMC10580629 DOI: 10.1186/s13027-023-00536-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/13/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND WHO has recommended HPV testing for cervical screening where it is practical and affordable. If used, it is important to both clarify and implement the clinical management of positive results. We estimated the performance in Lusaka, Zambia of a novel screening/triage approach combining HPV typing with visual assessment assisted by a deep-learning approach called automated visual evaluation (AVE). METHODS In this well-established cervical cancer screening program nested inside public sector primary care health facilities, experienced nurses examined women with high-quality digital cameras; the magnified illuminated images permit inspection of the surface morphology of the cervix and expert telemedicine quality assurance. Emphasizing sensitive criteria to avoid missing precancer/cancer, ~ 25% of women screen positive, reflecting partly the high HIV prevalence. Visual screen-positive women are treated in the same visit by trained nurses using either ablation (~ 60%) or LLETZ excision, or referred for LLETZ or more extensive surgery as needed. We added research elements (which did not influence clinical care) including collection of HPV specimens for testing and typing with BD Onclarity™ with a five channel output (HPV16, HPV18/45, HPV31/33/52/58, HPV35/39/51/56/59/66/68, human DNA control), and collection of triplicate cervical images with a Samsung Galaxy J8 smartphone camera™ that were analyzed using AVE, an AI-based algorithm pre-trained on a large NCI cervical image archive. The four HPV groups and three AVE classes were crossed to create a 12-level risk scale, ranking participants in order of predicted risk of precancer. We evaluated the risk scale and assessed how well it predicted the observed diagnosis of precancer/cancer. RESULTS HPV type, AVE classification, and the 12-level risk scale all were strongly associated with degree of histologic outcome. The AVE classification showed good reproducibility between replicates, and added finer predictive accuracy to each HPV type group. Women living with HIV had higher prevalence of precancer/cancer; the HPV-AVE risk categories strongly predicted diagnostic findings in these women as well. CONCLUSIONS These results support the theoretical efficacy of HPV-AVE-based risk estimation for cervical screening. If HPV testing can be made affordable, cost-effective and point of care, this risk-based approach could be one management option for HPV-positive women.
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Affiliation(s)
- Groesbeck P Parham
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia.
| | - Didem Egemen
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Brian Befano
- Information Management Services Inc, Calverton, MD, USA
| | | | - Ana Cecilia Rodriguez
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Sameer Antani
- National Library of Medicine, NIH, Bethesda, MD, 20892, USA
| | - Samson Chisele
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | - Friday Kaunga
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Francis Musonda
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | - Evans Malyangu
- Women and Newborn Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | - Silvia de Sanjose
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA
| | - Mark Schiffman
- HPV-AVE (PAVE) Initiative, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20850, USA.
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Lopez-Ampuero C, Hansen N, Alvarez Larraondo M, Taipe-Quico R, Cerna-Ayala J, Desai K, Egemen D, Schiffman M, Jeronimo J. Squamocolumnar junction visibility among cervical cancer screening population in Peru might influence upper age for screening programs. Prev Med 2023; 174:107596. [PMID: 37451555 DOI: 10.1016/j.ypmed.2023.107596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
Cervical cancer screening and treatment of screen positives is an important and effective strategy to reduce cervical cancer morbidity and mortality. In order to have an accurate cervical cancer screening and evaluation of positives, the entire Squamocolumnar Junction (SCJ) must be visible. Throughout the life course, the position of the SCJ changes and affects its visibility. SCJ visibility was analyzed among participants screened at the League Against Cancer Clinic in Lima, Peru. Of the 4247 participants screened, the SCJ was fully visible in 49.7% of participants, partially visible in 23.1%, and not visible in 27.2%. Visibility decreased with age, and by age 45 years old, the SCJ was not fully visible in over 50% of participants. Our results show that a high percentage of participants at ages still recommended for screening do not have totally visible SCJ, and we may need to reconsider the upper age limit for screening and find new strategies for evaluation of those with a positive screening test and non-visible SCJ.
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Affiliation(s)
| | | | | | | | | | - Kanan Desai
- National Cancer Institute, USA; Internal Medicine, ICHAN School of Medicine, Mt. Sinai, Elmhurst Hospital Center, USA
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Akakpo PK, Ken-Amoah S, Enyan NIE, Agyare E, Salia E, Baidoo I, Derkyi-Kwarteng L, Asare M, Adjei G, Addo SA, Obiri-Yeboah D. High-risk human papillomavirus genotype distribution among women living with HIV; implication for cervical cancer prevention in a resource limited setting. Infect Agent Cancer 2023; 18:33. [PMID: 37237313 DOI: 10.1186/s13027-023-00513-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 05/22/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND For women living with HIV (WLHIV), the burden of persistent HPV infection, cervical pre-cancerous lesions and cancer have been demonstrated to be higher than among HIV-negative women. As Ghana and other lower-middle-income countries (LMIC) work toward developing national cervical cancer programmes, it is essential that local scientific evidence be provided to guide policy decisions, especially for such special populations. The objective of this study was to determine the distribution of high-risk HPV genotype and related factors among WLHIV and its implication for the prevention of cervical cancer prevention efforts. METHODS A cross-sectional study was conducted at the Cape Coast Teaching Hospital in Ghana. WLHIV, aged 25-65 years, who met the eligibility criteria were recruited through a simple random sampling method. An interviewer-administered questionnaire was used to gather socio-demographic, behavioural, clinical and other pertinent information. The AmpFire HPV detection system (Atila BioSystem, Mointain View, CA was used to detect 15 high-risk HPV genotypes from self-collected cervico-vaginal samples. The data collected were exported to STATA 16.0 for statistical analysis. RESULTS In all, 330 study participants, with mean age of 47.2 years (SD ± 10.7), were involved. Most (69.1%, n = 188/272) had HIV viral loads < 1000 copies/ml and 41.2% (n = 136) had ever heard of cervical screening. The overall hr-HPV prevalence was 42.7% (n = 141, 95% CI 37.4-48.1) and the five commonest hr-HPV types among screen positives were HPV59 (50.4%), HPV18 (30.5%), HPV35 (26.2%), HPV58 (17%) and HPV45 (14.9%). Most infected women (60.3%, n = 85) had multiple hr-HPV infections, with about 57.4% (n = 81) having 2-5 h-HPV types, while 2.8% (n = 4) had more than five hr-HPV types. A total of 37.6% (n = 53) had HPV16 and/or18, while 66.0% (n = 93) had the hr-HPV genotypes covered by the nonavalent vaccine. Women with HIV viral load ≥ 1000copies/ml (AOR = 5.58, 95% CI 2.89-10.78, p < 0.001) had a higher likelihood of being co-infected. CONCLUSION This study found out that the prevalence of hr-HPV still remains high in women with HIV, with a notable occurrence of multiple infections and infection with genotypes 16 and/or18. Additionally, an association was established between hr-HPV and infection HIV viral load.. Therefore, comprehensive HIV care for these women should include awareness of cervical cancer, consideration of vaccination and implementation of screening and follow-up protocols. National programmes in LMIC, such as Ghana, should consider using HPV-based screen-triage-treat approach with partial genotyping.
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Affiliation(s)
- Patrick Kafui Akakpo
- Department of Anatomic Pathology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Sebastian Ken-Amoah
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Nancy Innocentia Ebu Enyan
- Department of Adult Health, School of Nursing and Midwifery, University of Cape Coast, Cape Coast, Ghana
| | - Elizabeth Agyare
- Public Health Unit, Cape Coast Teaching Hospital, Cape Coast, Ghana
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Emmanuel Salia
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Ibrahim Baidoo
- Public Health Unit, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Leonard Derkyi-Kwarteng
- Department of Anatomic Pathology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Matthew Asare
- Department of Public Health, Robbins College of Health and Human Services, Baylor University, Waco, TX, USA
| | - George Adjei
- Department of Community Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Dorcas Obiri-Yeboah
- Public Health Unit, Cape Coast Teaching Hospital, Cape Coast, Ghana.
- Department of Microbiology and Immunology, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana.
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Perkins RB, Smith DL, Jeronimo J, Campos NG, Gage JC, Hansen N, Rodriguez AC, Cheung LC, Egemen D, Befano B, Novetsky AP, Martins S, Kalpathy-Cramer J, Inturrisi F, Ahmed SR, Marcus J, Wentzensen N, de Sanjose S, Schiffman M. Use of risk-based cervical screening programs in resource-limited settings. Cancer Epidemiol 2023; 84:102369. [PMID: 37105017 DOI: 10.1016/j.canep.2023.102369] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023]
Abstract
Cervical cancer screening and management in the U.S. has adopted a risk-based approach. However, the majority of cervical cancer cases and deaths occur in resource-limited settings, where screening and management are not widely available. We describe a conceptual model that optimizes cervical cancer screening and management in resource-limited settings by utilizing a risk-based approach. The principles of risk-based screening and management in resource limited settings include (1) ensure that the screening method effectively separates low-risk from high-risk patients; (2) directing resources to populations at the highest cancer risk; (3) screen using HPV testing via self-sampling; (4) utilize HPV genotyping to improve risk stratification and better determine who will benefit from treatment, and (5) automated visual evaluation with artificial intelligence may further improve risk stratification. Risk-based screening and management in resource limited settings can optimize prevention by focusing triage and treatment resources on the highest risk patients while minimizing interventions in lower risk patients.
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Affiliation(s)
- Rebecca B Perkins
- Boston University Chobanian and Avedisian School of Medicine/Boston Medical Center, Boston, MA, USA.
| | | | | | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Li C Cheung
- National Cancer Institute, Bethesda, MD, USA
| | | | - Brian Befano
- Information Management Services Inc, 3901 Calverton Blvd Suite 200, Calverton, MD, USA
| | - Akiva P Novetsky
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | | | | | - Syed Rakin Ahmed
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA 02129, USA; Harvard Graduate Program in Biophysics, Harvard Medical School, Harvard University, Cambridge, MA 02115, USA; Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH 02139,USA
| | - Jenna Marcus
- Feinberg School of Medicine at Northwestern University, Chicago, IL, USA
| | | | - Silvia de Sanjose
- National Cancer Institute, Bethesda, MD, USA; ISGlobal, Barcelona, Spain
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de Sanjose S. Colposcopy for cervical screening in low-resource settings. Lancet Glob Health 2023; 11:e304-e305. [PMID: 36796965 DOI: 10.1016/s2214-109x(23)00014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023]
Affiliation(s)
- Silvia de Sanjose
- National Cancer Institute, Bethesda, MD 20814, USA; ISGlobal, Barcelona, Spain.
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10
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Di Gennaro G, Licata F, Trovato A, Bianco A. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Front Public Health 2022; 10:1003461. [PMID: 36568753 PMCID: PMC9773849 DOI: 10.3389/fpubh.2022.1003461] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples. Methods The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools. Results One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely. Conclusions Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.
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Affiliation(s)
| | - Francesca Licata
- Department of Health Sciences, School of Medicine, University of Catanzaro “Magna Græcia”, Catanzaro, Italy
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11
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Mremi A, Mchome B, Mlay J, Schledermann D, Blaakær J, Rasch V. Performance of HPV testing, Pap smear and VIA in women attending cervical cancer screening in Kilimanjaro region, Northern Tanzania: a cross-sectional study nested in a cohort. BMJ Open 2022; 12:e064321. [PMID: 36316070 PMCID: PMC9628663 DOI: 10.1136/bmjopen-2022-064321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE There is a concern about performance of the screening approaches, where information on the quality of novel and affordable screening approaches that will perform well in remote areas is warranted. This lack of information makes it difficult to prioritise resource use in efforts to improve cervical cancer outcomes. We aimed to compare the diagnostic value of human papillomavirus (HPV) testing on self-collected samples, Pap smear and visual inspection of the cervix with acetic acid (VIA) tests for detection of high-grade cervical intraepithelial neoplasia or worse (CIN2+). DESIGN A combined cross-sectional and cohort study. SETTING Three primary healthcare centres in Kilimanjaro region, Tanzania. PARTICIPANTS 1620 women undergoing cervical cancer screening from December 2018 to September 2021. Inclusion criteria were being aged 25-60 years, and no history of premalignant or cervical cancer. Exclusion criteria were overt signs of cancer and previous hysterectomy. INTERVENTIONS Participants underwent HPV self-sampling with Evalyn Brush and Care HPV kit assay was used to determine prevalence of high-risk HPV infection. Women with positive HPV test were together with a random sample of HPV negative women scheduled for follow-up where VIA was performed, and Pap smear and cervical biopsies obtained. RESULTS Of 1620 women enrolled, 229 (14.1%) were HPV positive and 222 of these attended follow-up together with 290 (20.8%) women with negative HPV test. On VIA, 17.6% were positive. On Pap smear, 8.0% were classified as high-grade squamous intraepithelial lesion. The sensitivity and specificity, respectively, of the various tests, compared with histopathology for the detection of CIN2+ were: HPV test 62.5%, 59.3%; Pap smear 82.8%, 82.1% and; VIA 48.4%, 56.8%. When combined, the sensitivity and specificity for HPV and Pap smear were 90.6%, 70.6% while HPV and VIA were 65.6% and 75.5% for the detection of CIN2+. CONCLUSIONS The performance of care HPV testing on self-collected samples opens the possibility of increasing coverage and early detection in resource-constrained settings.
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Affiliation(s)
- Alex Mremi
- Department of Pathology, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Bariki Mchome
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Joseph Mlay
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | | | - Jan Blaakær
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Vibeke Rasch
- Odense University Hospital, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Department of Clinical Research, Odense University Hospital, Odense, Denmark
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12
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Feng N, Ezechi O, Uwandu M, Abimbola BS, Vincent GD, Idigbe I, Okoli LC, Adesina M, Okwuzu J, Ahmed RA, Sokei J, Shaibu JO, Momoh AE, Sowunmi O, Labo-Popoola OH, Ohihoin G, David A, Nzeribe E, Olaleye O, Dong XP, Onwuamah CK. Self-collected versus medic-collected sampling for human papillomavirus testing among women in Lagos, Nigeria: a comparative study. BMC Public Health 2022; 22:1922. [PMID: 36243709 PMCID: PMC9569041 DOI: 10.1186/s12889-022-14222-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and performance of self-collected vaginal swab samples for HPV screening among women in Lagos, Nigeria. METHODS A cross-sectional study was implemented from March to August 2020 among sexually active women. Study participants provided same-day paired vaginal swab samples. Medic-sampling and poster-directed self-sampling methods were used to collect the two samples per participant. A real-time PCR assay detected HPV 16, HPV 18, other-high-risk (OHR) HPV, and the human β-globin gene. The self-collected samples' sensitivity, specificity, and accuracy were determined against the medic-collected samples using the MedCalc Online Diagnostic Calculator. RESULTS Of the 213 women aged 16 ~ 63-year-old recruited, 187 (88%) participants had concordant results, while 26 (12%) participants had discordant results. Among the 187 concordant results, 35 (19%) were HPV positive, 150 (80%) participants were HPV negative, and two (1%) were invalid. 18 (69%) out of the 26 discordant samples were invalid. The self-collected sample was invalid for 14 (54%) participants. Two (8%) medic-collected samples were invalid. Compared to the medic-collected sample, the self-collected sample was 89.80% (95% CI: 77.77 ~ 96.60%) sensitive and 98.21% (95% CI: 94.87 ~ 99.63%) specific, with an accuracy of 96.31% (95% CI: 92.87 ~ 98.40%). The mean age for HPV positive and negative participants were 39 and 40, respectively, with an ANOVA p-value of 0.3932. The stratification of HPV infection by the age group was not statistically significant (P > 0.05). CONCLUSIONS With high accuracy of 96%, self-collected sampling is adequate when tested with real-time PCR and may increase the uptake of HPV testing. Though more self-collected samples were invalid than medic-collected samples, most likely due to poor collection, they could be identified for repeat testing. Future implementation can avoid this error with improved guidance and awareness.
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Affiliation(s)
- Ning Feng
- Center for Global Public Health, Chinese Centre for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China
| | - Oliver Ezechi
- Department of Clinical Sciences, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Mabel Uwandu
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Bowofoluwa Sharon Abimbola
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Grace Deborah Vincent
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Ifeoma Idigbe
- Department of Clinical Sciences, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Leona Chika Okoli
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Mary Adesina
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Jane Okwuzu
- Department of Clinical Sciences, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Rahaman Ademolu Ahmed
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Judith Sokei
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Joseph Ojonugwa Shaibu
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Abidemi Esther Momoh
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Omowunmi Sowunmi
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Olaoniye Habeebat Labo-Popoola
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | | | - Greg Ohihoin
- Department of Clinical Sciences, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Agatha David
- Department of Clinical Sciences, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria
| | - Emily Nzeribe
- Federal Medical Centre, 105 Orlu Road, Owerri, Imo State, Nigeria
| | | | - Xiao-Ping Dong
- National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing, 102206, China.
| | - Chika Kingsley Onwuamah
- Centre for Human Virology and Genomics, Department of Microbiology, Nigerian Institute of Medical Research, 6 Edmund Crescent, Yaba, Lagos, Nigeria.
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Desai KT, Adepiti CA, Schiffman M, Egemen D, Gage JC, Wentzensen N, de Sanjose S, Burk RD, Ajenifuja KO. Redesign of a rapid, low-cost HPV typing assay to support risk-based cervical screening and management. Int J Cancer 2022; 151:1142-1149. [PMID: 35666530 PMCID: PMC9378567 DOI: 10.1002/ijc.34151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/21/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
Abstract
Accelerated cervical cancer control will require widespread human papillomavirus (HPV) vaccination and screening. For screening, sensitive HPV testing with an option of self-collection is increasingly desirable. HPV typing predicts risk of precancer/cancer, which could be useful in management, but most current typing assays are expensive and/or complicated. An existing 15-type isothermal amplification assay (AmpFire, Atila Biosystems, USA) was redesigned as a 13-type assay (ScreenFire) for public health use. The redesigned assay groups HPV types into four channels with differential cervical cancer risk: (a) HPV16, (b) HPV18/45, (c) HPV31/33/35/52/58 and (d) HPV39/51/56/59/68. Since the assay will be most useful in resource-limited settings, we chose a stratified random sample of 453 provider-collected samples from a population-based screening study in rural Nigeria that had been initially tested with MY09-MY11-based PCR with oligonucleotide hybridization genotyping. Frozen residual specimens were masked and retested at Atila Biosystems. Agreement on positivity between ScreenFire and prior PCR testing was very high for each of the channels. When we simulated intended use, that is, a hierarchical result in order of clinical importance of the type groups (HPV16 > 18/45 > 31/33/35/52/58 > 39/51/56/59/68), the weighted kappa for ScreenFire vs PCR was 0.90 (95% CI: 0.86-0.93). The ScreenFire assay is mobile, relatively simple, rapid (results within 20-60 minutes) and agrees well with reference testing particularly for the HPV types of greatest carcinogenic risk. If confirmed, ScreenFire or similar isothermal amplification assays could be useful as part of risk-based screening and management.
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Affiliation(s)
- Kanan T. Desai
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
| | - Clement A. Adepiti
- Department of Obstetrics, Gynecology, and PerinatologyThe Obafemi Awolowo UniversityIle‐IfeOsun StateNigeria
| | - Mark Schiffman
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
| | - Didem Egemen
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
| | - Julia C. Gage
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
| | - Nicolas Wentzensen
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
| | - Silvia de Sanjose
- Clinical Epidemiology Unit, Clinical Genetic Branch, Division of Cancer Epidemiology and GeneticsNational Cancer InstituteRockvilleMarylandUSA
- ISGlobalBarcelonaSpain
| | - Robert D. Burk
- Albert Einstein Cancer CenterAlbert Einstein College of MedicineNew YorkNew YorkUSA
| | - Kayode O. Ajenifuja
- Department of Obstetrics, Gynecology, and PerinatologyThe Obafemi Awolowo UniversityIle‐IfeOsun StateNigeria
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14
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Xue Z, Angara S, Guo P, Rajaraman S, Jeronimo J, Rodriguez AC, Alfaro K, Charoenkwan K, Mungo C, Domgue JF, Wentzensen N, Desai KT, Ajenifuja KO, Wikström E, Befano B, de Sanjosé S, Schiffman M, Antani S. Image Quality Classification for Automated Visual Evaluation of Cervical Precancer. MEDICAL IMAGE LEARNING WITH LIMITED AND NOISY DATA : FIRST INTERNATIONAL WORKSHOP, MILLAND 2022, HELD IN CONJUNCTION WITH MICCAI 2022, SINGAPORE, SEPTEMBER 22, 2022, PROCEEDINGS. MILLAND (WORKSHOP) (1ST : 2022 : SINGAPORE) 2022; 13559:206-217. [PMID: 36315110 PMCID: PMC9614805 DOI: 10.1007/978-3-031-16760-7_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Image quality control is a critical element in the process of data collection and cleaning. Both manual and automated analyses alike are adversely impacted by bad quality data. There are several factors that can degrade image quality and, correspondingly, there are many approaches to mitigate their negative impact. In this paper, we address image quality control toward our goal of improving the performance of automated visual evaluation (AVE) for cervical precancer screening. Specifically, we report efforts made toward classifying images into four quality categories ("unusable", "unsatisfactory", "limited", and "evaluable") and improving the quality classification performance by automatically identifying mislabeled and overly ambiguous images. The proposed new deep learning ensemble framework is an integration of several networks that consists of three main components: cervix detection, mislabel identification, and quality classification. We evaluated our method using a large dataset that comprises 87,420 images obtained from 14,183 patients through several cervical cancer studies conducted by different providers using different imaging devices in different geographic regions worldwide. The proposed ensemble approach achieved higher performance than the baseline approaches.
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Affiliation(s)
- Zhiyun Xue
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
| | - Sandeep Angara
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
| | - Peng Guo
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
| | | | - Jose Jeronimo
- National Cancer Institute, National Institutes of Health, Rockville, MD 20850, USA
| | | | | | - Kittipat Charoenkwan
- Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand 50200
| | - Chemtai Mungo
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joel Fokom Domgue
- Cameroon Baptist Convention Health Services, Bamenda, North West Region, Cameroon
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaoundé, Cameroon
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicolas Wentzensen
- National Cancer Institute, National Institutes of Health, Rockville, MD 20850, USA
| | - Kanan T Desai
- National Cancer Institute, National Institutes of Health, Rockville, MD 20850, USA
| | | | - Elisabeth Wikström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Brian Befano
- Information Management Services, Calverton, MD, USA
| | - Silvia de Sanjosé
- National Cancer Institute, National Institutes of Health, Rockville, MD 20850, USA
| | - Mark Schiffman
- National Cancer Institute, National Institutes of Health, Rockville, MD 20850, USA
| | - Sameer Antani
- National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
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15
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Shastri SS, Temin S, Almonte M, Basu P, Campos NG, Gravitt PE, Gupta V, Lombe DC, Murillo R, Nakisige C, Ogilvie G, Pinder LF, Poli UR, Qiao Y, Woo YL, Jeronimo J. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Guideline Update. JCO Glob Oncol 2022; 8:e2200217. [PMID: 36162041 PMCID: PMC9812449 DOI: 10.1200/go.22.00217] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To update resource-stratified, evidence-based recommendations on secondary prevention of cervical cancer globally. METHODS American Society of Clinical Oncology convened a multidisciplinary, multinational Expert Panel to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, formal consensus-based process, and modified ADAPTE process to adapt existing guidelines was conducted. Other experts participated in formal consensus. RESULTS This guideline update reflects changes in evidence since the previous update. Five existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement. RECOMMENDATIONS Human papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies vary by the following setting: maximal: age 25-65 years, every 5 years; enhanced: age 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: age 30-49 years, every 10 years; basic: age 30-49 years, one to three times per lifetime. For basic settings, visual assessment is used to determine treatment eligibility; in other settings, genotyping with cytology or cytology alone is used to determine treatment. For basic settings, treatment is recommended if abnormal triage results are obtained; in other settings, abnormal triage results followed by colposcopy is recommended. For basic settings, treatment options are thermal ablation or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure or ablation is recommended; with a 12-month follow-up in all settings. Women who are HIV-positive should be screened with HPV testing after diagnosis, twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information is available at www.asco.org/resource-stratified-guidelines.
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Affiliation(s)
| | - Sarah Temin
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | - Nicole G Campos
- Harvard University T.H. Chan School of Public Health, Boston, MA
| | | | | | - Dorothy C Lombe
- Regional Cancer Treatment Services, MidCentral District Health Board, Palmerston North, New Zealand
| | | | | | | | | | - Usha R Poli
- India Institute of Public Health, Hyderabad, India
| | - Youlin Qiao
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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16
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Mafiana JJ, Dhital S, Halabia M, Wang X. Barriers to uptake of cervical cancer screening among women in Nigeria: a systematic review. Afr Health Sci 2022; 22:295-309. [PMID: 36407354 PMCID: PMC9652621 DOI: 10.4314/ahs.v22i2.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Cervical cancer is the second most frequent cancer and cause of cancer-related deaths among women in Nigeria. The Visual inspection with acetic acid and cryotherapy "see and treat" screening approach is a feasible and effective method that can be implemented in low resource settings like Nigeria; however, screening utilization is still low. OBJECTIVE This systematic review aims at offering a comprehensive synthesis of studies that assessed the barriers preventing women from utilizing cervical cancer screening services in Nigeria. METHODS Electronic data search was performed on PubMed, Cochrane Library, EMbase, Directory of Open Access Journals, Google Scholar, and ScienceDirect, and quality assessment was conducted for the included studies. Data were extracted independently by two authors and thematically analysed for barriers to cervical cancer screening utilization. RESULTS Fifteen studies, consisting of 9,995 women aged 15 and above published between 2007 and 2020, were included. Frequently reported barriers to cervical screening include lack of knowledge of cervical cancer and screening, health service factors, screening is unnecessary, fear of outcome and procedure, and financial constraints. CONCLUSION Lack of adequate information about cervical cancer is a significant hindrance to screening; this factor is strongly associated with the numerous misconceptions and negative perceptions. The study highlights the need for further assessment of the sociodemographic determinants of cervical cancer screening uptake in Nigeria. Preventive strategies should be targeted at improving the dissemination of valid information, reducing the knowledge gap among women, and addressing the financial and health service factors.
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Affiliation(s)
- Joy J Mafiana
- School of Public Health, Lanzhou University, Lanzhou 730000, China
| | - Sushma Dhital
- School of Public Health, Lanzhou University, Lanzhou 730000, China
| | | | - Xiaohui Wang
- School of Public Health, Lanzhou University, Lanzhou 730000, China
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17
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John-Akinola YO, Ndikom CM, Oluwasanu MM, Adebisi T, Odukoya O. Cervical Cancer and Human Papillomavirus Vaccine Knowledge, Utilisation, Prevention Educational Interventions and Policy Response in Nigeria: A Scoping Review. Cancer Control 2022; 29:10732748221130180. [PMID: 36168955 PMCID: PMC9523857 DOI: 10.1177/10732748221130180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE This review evaluated the knowledge, utilisation, prevention education, and policy response across the six geopolitical regions of Nigeria to inform national efforts for the prevention and control of cervical cancer. METHODS A keyword-based systematic search was conducted in PubMed/MEDLINE (NCBI), Google Scholar, and AJOL electronic databases, including a manual scan of papers, journals and websites to identify relevant peer-reviewed studies. Articles were screened and assessed for eligibility. RESULTS Many (158) articles were downloaded and after duplicates were removed, 110 articles were included in the final analysis. These were made up of qualitative, quantitative (cross-sectional), intervention and policy studies. Studies have generally reported poor knowledge and awareness of cervical cancer screening but those carried out in urban areas demonstrated a slightly higher level of awareness of Human Papilloma Virus (HPV) vaccine, HPV vaccination uptake and utilization of cervical cancer preventive services than the rural studies. The studies did not show strong government support or policies in relation to cervical cancer control. CONCLUSION Knowledge and uptake of cervical cancer preventive services across diverse groups in Nigeria remain poor. These could be linked to socio-cultural factors, the lack of an organised cervical cancer screening programme and low financial resource pool for cervical cancer prevention. Therefore, it is necessary to increase government, donor prioritisation and political support in order to ensure increased investment and commitment to cervical cancer elimination in Nigeria.
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Affiliation(s)
- Yetunde O John-Akinola
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, 113092University of Ibadan, Ibadan, Nigeria
| | - Chizoma M Ndikom
- Department of Nursing, College of Medicine, 113092University of Ibadan, Ibadan, Nigeria
| | - Mojisola M Oluwasanu
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, 113092University of Ibadan, Ibadan, Nigeria
| | - Temitayo Adebisi
- Department of Radiation Oncology, 107962University College Hospital, Ibadan, Nigeria
| | - Oluwaponmile Odukoya
- Department of Radiation Oncology, College of Medicine, 113092University of Ibadan, Ibadan, Nigeria
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18
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Desai KT, Befano B, Xue Z, Kelly H, Campos NG, Egemen D, Gage JC, Rodriguez AC, Sahasrabuddhe V, Levitz D, Pearlman P, Jeronimo J, Antani S, Schiffman M, de Sanjosé S. The development of "automated visual evaluation" for cervical cancer screening: The promise and challenges in adapting deep-learning for clinical testing. Int J Cancer 2021; 150:741-752. [PMID: 34800038 PMCID: PMC8732320 DOI: 10.1002/ijc.33879] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/24/2021] [Accepted: 10/15/2021] [Indexed: 12/22/2022]
Abstract
There is limited access to effective cervical cancer screening programs in many resource‐limited settings, resulting in continued high cervical cancer burden. Human papillomavirus (HPV) testing is increasingly recognized to be the preferable primary screening approach if affordable due to superior long‐term reassurance when negative and adaptability to self‐sampling. Visual inspection with acetic acid (VIA) is an inexpensive but subjective and inaccurate method widely used in resource‐limited settings, either for primary screening or for triage of HPV‐positive individuals. A deep learning (DL)‐based automated visual evaluation (AVE) of cervical images has been developed to help improve the accuracy and reproducibility of VIA as assistive technology. However, like any new clinical technology, rigorous evaluation and proof of clinical effectiveness are required before AVE is implemented widely. In the current article, we outline essential clinical and technical considerations involved in building a validated DL‐based AVE tool for broad use as a clinical test.
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Affiliation(s)
- Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Brian Befano
- Information Management Services Inc., Calverton, Maryland, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Zhiyun Xue
- US National Library of Medicine, Bethesda, Maryland, USA
| | - Helen Kelly
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Nicole G Campos
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Julia C Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Ana-Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | | | - David Levitz
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Paul Pearlman
- Center for Global Health, National Cancer Institute, Rockville, Maryland, USA
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Sameer Antani
- US National Library of Medicine, Bethesda, Maryland, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA.,ISGlobal, Barcelona, Spain
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19
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Castle PE, Einstein MH, Sahasrabuddhe VV. Cervical cancer prevention and control in women living with human immunodeficiency virus. CA Cancer J Clin 2021; 71:505-526. [PMID: 34499351 PMCID: PMC10054840 DOI: 10.3322/caac.21696] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022] Open
Abstract
Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.
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Affiliation(s)
- Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Vikrant V Sahasrabuddhe
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
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20
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Torres KL, Rondon HHDMF, Martins TR, Martins S, Ribeiro A, Raiol T, Marques CP, Corrêa F, Migowski A, Minuzzi-Souza TTCE, Schiffman M, Rodriguez AC, Gage JC. Moving towards a strategy to accelerate cervical cancer elimination in a high-burden city-Lessons learned from the Amazon city of Manaus, Brazil. PLoS One 2021; 16:e0258539. [PMID: 34662368 PMCID: PMC8523067 DOI: 10.1371/journal.pone.0258539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
The World Health Organization Call to Eliminate Cervical Cancer resonates in cities like Manaus, Brazil, where the burden is among the world’s highest. Manaus has offered free cytology-based screening since 1990 and HPV immunization since 2013, but the public system is constrained by many challenges and performance is not well-defined. We obtained cervical cancer prevention activities within Manaus public health records for 2019 to evaluate immunization and screening coverage, screening by region and neighborhood, and the annual Pink October screening campaign. We estimated that among girls and boys age 14–18, 85.9% and 64.9% had 1+ doses of HPV vaccine, higher than rates for age 9–13 (73.4% and 43.3%, respectively). Of the 90,209 cytology tests performed, 24.9% were outside the target age and the remaining 72,230 corresponded to 40.1% of the target population (one-third of women age 25–64). The East zone had highest screening coverage (49.1%), highest high-grade cytology rate (2.5%) and lowest estimated cancers (38.1/100,000) compared with the South zone (32.9%, 1.8% and 48.5/100,000, respectively). Largest neighborhoods had fewer per capita screening locations, resulting in lower coverage. During October, some clinics successfully achieved higher screening volumes and high-grade cytology rates (up to 15.4%). Although we found evidence of some follow-up within 10 months post-screening for 51/70 women (72.9%) with high-grade or worse cytology, only 18 had complete work-up confirmed. Manaus has successfully initiated HPV vaccination, forecasting substantial cervical cancer reductions by 2050. With concerted efforts during campaigns, some clinics improved screening coverage and reached high-risk women. Screening campaigns in community locations in high-risk neighborhoods using self-collected HPV testing can achieve widespread coverage. Simplifying triage and treatment with fewer visits closer to communities would greatly improve follow-up and program effectiveness. Achieving WHO Cervical Cancer Elimination goals in high-burden cities will require major reforms for screening and simpler follow-up and treatment.
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Affiliation(s)
- Kátia Luz Torres
- Amazon State Oncology Control Foundation (FCECON), Manaus, Amazonas, Brazil
- Post Graduation Program in Health Sciences and Basic and Applied Immunology at The Federal University of Amazonas (UFAM), Manaus, Amazonas, Brazil
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- * E-mail:
| | - Heidy Halanna de Melo Farah Rondon
- Post Graduation Program in Health Sciences and Basic and Applied Immunology at The Federal University of Amazonas (UFAM), Manaus, Amazonas, Brazil
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Toni Ricardo Martins
- Tropical Medicine Institute, São Paulo University, Virology Laboratory (LIM52) (USP-SP) - São Paulo, São Paulo, Brazil
| | - Sandro Martins
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Ana Ribeiro
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- Department of Pharmacy, Faculty of Health Sciences, University of Brasília (UNB), Brasília, Federal District, Brazil
| | - Taina Raiol
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
| | - Carla Pintas Marques
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- Collective Health, Universidade de Brasília (UnB), Brasília, Federal District, Brazil
| | - Flavia Corrêa
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arn Migowski
- Cancer Early Detection Division, Brazilian National Cancer Institute (INCA), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thais Tâmara Castro e Minuzzi-Souza
- Center for Epidemiology and Health Surveillance, Oswaldo Cruz Foundation (Fiocruz), Brasília, Federal District, Brazil
- National Immunization Program, Health Surveillance Secretariat (SVS), Ministry of Health, Brasília, Federal District, Brazil
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
| | - Julia C. Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, Bethesda, Maryland, United States of America
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21
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Shin MB, Liu G, Mugo N, Garcia PJ, Rao DW, Bayer CJ, Eckert LO, Pinder LF, Wasserheit JN, Barnabas RV. A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities. Front Public Health 2021; 9:670032. [PMID: 34277540 PMCID: PMC8281011 DOI: 10.3389/fpubh.2021.670032] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022] Open
Abstract
The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.
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Affiliation(s)
- Michelle B. Shin
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Gui Liu
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Patricia J. Garcia
- Department of Global Health, University of Washington, Seattle, WA, United States
- School of Public Health, Cayetano Heredia University, Lima, Peru
| | - Darcy W. Rao
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Cara J. Bayer
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Linda O. Eckert
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Leeya F. Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Judith N. Wasserheit
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
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22
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Xue Z, Guo P, Desai KT, Pal A, Ajenifuja KO, Adepiti CA, Long LR, Schiffman M, Antani S. A Deep Clustering Method For Analyzing Uterine Cervix Images Across Imaging Devices. PROCEEDINGS. IEEE INTERNATIONAL SYMPOSIUM ON COMPUTER-BASED MEDICAL SYSTEMS 2021; 2021:527-532. [PMID: 35445152 PMCID: PMC9017785 DOI: 10.1109/cbms52027.2021.00085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Visual inspection of the cervix with acetic acid (VIA), though error prone, has long been used for screening women and to guide management for cervical cancer. The automated visual evaluation (AVE) technique, in which deep learning is used to predict precancer based on a digital image of the acetowhitened cervix, has demonstrated its promise as a low-cost method to improve on human performance. However, there are several challenges in moving AVE beyond proof-of-concept and deploying it as a practical adjunct tool in visual screening. One of them is making AVE robust across images captured using different devices. We propose a new deep learning based clustering approach to investigate whether the images taken by three different devices (a common smartphone, a custom smartphone-based handheld device for cervical imaging, and a clinical colposcope equipped with SLR digital camera-based imaging capability) can be well distinguished from each other with respect to the visual appearance/content within their cervix regions. We argue that disparity in visual appearance of a cervix across devices could be a significant confounding factor in training and generalizing AVE performance. Our method consists of four components: cervix region detection, feature extraction, feature encoding, and clustering. Multiple experiments are conducted to demonstrate the effectiveness of each component and compare alternative methods in each component. Our proposed method achieves high clustering accuracy (97%) and significantly outperforms several representative deep clustering methods on our dataset. The high clustering performance indicates the images taken from these three devices are different with respect to visual appearance. Our results and analysis establish a need for developing a method that minimizes such variance among the images acquired from different devices. It also recognizes the need for large number of training images from different sources for robust device-independent AVE performance worldwide.
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Affiliation(s)
- Zhiyun Xue
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Peng Guo
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Kanan T Desai
- National Cancer Institute, National Institutes of Health, USA
| | - Anabik Pal
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | | | | | - L Rodney Long
- National Library of Medicine, National Institutes of Health, Bethesda, USA
| | - Mark Schiffman
- National Cancer Institute, National Institutes of Health, USA
| | - Sameer Antani
- National Library of Medicine, National Institutes of Health, Bethesda, USA
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23
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Wentzensen N, Chirenje ZM, Prendiville W. Treatment approaches for women with positive cervical screening results in low-and middle-income countries. Prev Med 2021; 144:106439. [PMID: 33678236 DOI: 10.1016/j.ypmed.2021.106439] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
The primary goal of cervical screening is to identify women with cervical precancers who need treatment to prevent invasive cervical cancer. Cervical cancer screening programs in high-resource settings rely on a multi-step process to reassure the majority of women of low cancer risk and treat the small number of women at high risk of precancer and cancer. The requirement of major resource investment for training and capacity building of multi-step cervical cancer screening programs prevents their introduction in low- and middle-income countries (LMICs). Screen-and-treat programs have been evaluated and introduced in some countries that use mainly ablative treatment as primary treatment options. Ablative treatment with cryotherapy and thermal ablation has a favorable tradeoff of benefits and harms and can be introduced more widely than excisional treatment in LMICs. While most women below 40 are eligible for ablative procedures, fewer than 50% are eligible by age 50 and ablative treatment is not appropriate over age 50. Excisional treatment is required for women ineligible for ablative treatment. Since screening programs in LMICs necessarily detect invasive cancers, cancer treatment and palliative care needs to be considered as well.
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Affiliation(s)
- Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
| | - Z Mike Chirenje
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe and Bixby Center for Global Health, UCSF, San Francisco, USA
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24
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Ajenifuja KO, Belinson J, Goldstein A, Desai KT, de Sanjose S, Schiffman M. Designing low-cost, accurate cervical screening strategies that take into account COVID-19: a role for self-sampled HPV typing2. Infect Agent Cancer 2020; 15:61. [PMID: 33072179 PMCID: PMC7556607 DOI: 10.1186/s13027-020-00325-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background We propose an economical cervical screening research and implementation strategy designed to take into account the typically slow natural history of cervical cancer and the severe but hopefully temporary impact of COVID-19. The commentary introduces the practical validation of some critical components of the strategy, described in three manuscripts detailing recent project results in Asia and Africa.The main phases of a cervical screening program are 1) primary screening of women in the general population, 2) triage testing of the small minority of women that screen positive to determine need for treatment, and 3) treatment of triage-positive women thought to be at highest risk of precancer or even cancer. In each phase, attention must now be paid to safety in relation to SARS-CoV-2 transmission. The new imperatives of the COVID-19 pandemic support self-sampled HPV testing as the primary cervical screening method. Most women can be reassured for several years by a negative test performed on a self-sample collected at home, without need of clinic visit and speculum examination. The advent of relatively inexpensive, rapid and accurate HPV DNA testing makes it possible to return screening results from self-sampling very soon after specimen collection, minimizing loss to follow-up. Partial HPV typing provides important risk stratification useful for triage of HPV-positive women. A second "triage" test is often useful to guide management. In lower-resource settings, visual inspection with acetic acid (VIA) is still proposed but it is inaccurate and poorly reproducible, misclassifying the risk stratification gained by primary HPV testing. A deep-learning based approach to recognizing cervical precancer, adaptable to a smartphone camera, is being validated to improve VIA performance. The advent and approval of thermal ablation permits quick, affordable and safe, immediate treatment at the triage clinic of the majority of HPV-positive, triage-positive women. Conclusions Overall, only a small percentage of women in cervical screening programs need to attend the hospital clinic for a surgical procedure, particularly when screening is targeted to the optimal age range for detection of precancer rather than older ages with decreased visual screening performance and higher risks of hard-to-treat outcomes including invasive cancer.
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Affiliation(s)
| | - Jerome Belinson
- Women's Health Institute, Cleveland Clinic, Cleveland, OH USA
| | | | - Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Clinical Epidemiology Unit, Clinical Genetics Branch, 9609 Medical Center Drive Room 6E544, Rockville, MD 20850 USA
| | - Silvia de Sanjose
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Clinical Epidemiology Unit, Clinical Genetics Branch, 9609 Medical Center Drive Room 6E544, Rockville, MD 20850 USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Clinical Epidemiology Unit, Clinical Genetics Branch, 9609 Medical Center Drive Room 6E544, Rockville, MD 20850 USA
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