Trends in the incidence of in situ and invasive cervical cancer by age group and histological type in Korea from 1993 to 2009

Retrospective analysis of cytology and high-risk HPV testing in 1067 endocervical adenocarcinomas and precursor lesions

BACKGROUND

Cytology and high-risk human papilloma virus (hrHPV) cotesting is the mainstay in the detection of cervical carcinoma.

METHODS

Endocervical adenocarcinoma (EAC) is divided into HPV-associated adenocarcinoma (HPVA) and HPV-independent adenocarcinoma (HPVI) by the World Health Organization classification (2020). The detection effect of cotesting is suggested to be different among EAC subtypes and precursors, but has not well-documented yet. In this study, the authors retrospectively analyzed cotesting among adenocarcinoma in situ (AIS), HPVA, and HPVI. The cohort included 569 AIS and 498 EAC consisting of 371 (74.5%) HPVA, 111 (22.3%) HPVI, and 16 (3.2%) adenocarcinoma, not otherwise specified.

RESULTS

The authors found that AIS patients were significantly younger than HPVA and HPVI (mean ± SD, years: 40.7 ± 8.6; HPVA, 44.8 ± 9.3; HPVI, 50.0 ± 11.3; p < .001) and had a higher prevalence of concurrent squamous intraepithelial lesions (75.5%, HPVA, 37.2%; HPVI, 12.6%; p < .001). The detection rate of hrHPV test or cytology was substantially higher in AIS and HPVA than in HPVI (97.7% and 90.2% vs. 16.5%, p < .001, or 71.1% and 71.9% vs. 60.7%, p = .042, respectively). Cytology and hrHPV cotesting was superior to a single test in the detection of EAC and AIS. The detection rate of cotesting amounted to 100% in AIS and 94.3% in HPVA but was substantially lower in HPVI (72.2%) (p < .001).

CONCLUSIONS

The authors conclude that cytology and hrHPV cotesting can maximize the detection effect for HPVA and AIS but is not optimal for HPVI.

Incidence and survival of gynecologic cancer including cervical, uterine, ovarian, vaginal, vulvar cancer and gestational trophoblastic neoplasia in Korea, 1999-2019: Korea Central Cancer Registry

OBJECTIVE

To investigate the incidence, trends, and survival rates of all gynecologic cancers using the Korea Central Cancer Registry (KCCR) database from 1999-2019.

METHODS

Gynecologic cancer data were obtained from the KCCR database between 1999 and 2019. Age-standardized incidence rates (ASRs), annual percentage changes, and average annual percentage changes (AAPCs) were calculated. The relative survival rate (RSR) was reported by age group, stage, and 6-year period (I: 1999-2005, II: 2006-2012, III: 2013- 2019).

RESULTS

The gynecologic cancer ASRs were 26.2 and 24.9 per 100,000 individuals in 1999 and 2019, respectively. Trends of incidence in gynecologic cancer revealed a decrease in cervical cancer and gestational trophoblastic neoplasia (GTN) with AAPCs of -3.4 and -4.3, respectively. Conversely, the incidence of uterine, ovarian, and vulvar cancers increased with AAPCs of 4.7, 2.3, and 2.1, respectively. AAPC for vaginal cancer showed no change. The 5-year survival rate was highest for GTN (90.5%) and lowest for vaginal cancer (56.6%). An increase in age was correlated with poorer survival rates across all gynecologic cancers, excluding vaginal cancer. For all gynecologic cancer types, the prognosis deteriorates with advancing cancer stages. The RSR of uterine cancer improved consistently across all periods. The ovarian cancer RSR improved more in period III than in periods I or II. Additionally, the vulvar cancer RSR improved more in periods II and III than in period I.

CONCLUSION

In Korea, the incidence of cervical cancer and GTN decreased, whereas the incidence of uterine, ovarian, and vulvar cancer increased from 1999 to 2019. The RSR for uterine, ovarian, and vulvar cancers showed consistent improvements over different periods. Effective screening programs and the adoption of advanced treatments may be necessary to further reduce the burden of gynecologic cancer.

Molecular correlates of invasion pattern in HPV-associated endocervical adenocarcinoma: emergence of two distinct risk-stratified tiers

BACKGROUND

The pattern-based (Silva) classification of invasive human papilloma virus (HPV)-associated endocervical adenocarcinomas (HPVA) is an established and reproducible method to predict outcomes for this otherwise stage-dependent group of tumours. Previous studies utilising targeted sequencing have shown a correlation between mutational profiles and an invasive pattern. However, such correlation has not been explored using comprehensive molecular testing.

DESIGN

Clinicopathologic data including invasive pattern (Silva groups A, B, and C) was collected for a cohort of invasive HPVA, which previously underwent massive parallel sequencing using a panel covering 447 genes. Pathogenic alterations, molecular signatures, tumour mutational burden (TMB), and copy number alterations (CNA) were correlated with pattern of invasion.

RESULTS

Forty five HPVA (11 pattern A, 17 pattern B, and 17 pattern C tumours) were included. Patients with pattern A presented at stage I with no involved lymph nodes or evidence of recurrence (in those with >2 months of follow-up). Patterns B and C patients also mostly presented at stage I with negative lymph nodes, but had a greater frequency of recurrence; 3/17 pattern B and 1/17 pattern C HPVAs harboured lymphovascular space invasion (LVI). An APOBEC mutational signature was detected only in Silva pattern C tumours (5/17), and pathogenic PIK3CA changes were detected only in destructively invasive HPVA (patterns B and C). When cases were grouped as low-risk (pattern A and pattern B without LVI) and high-risk (pattern B with LVI and pattern C), high-risk tumours were enriched in mutations in PIK3CA, ATRX, and ERBB2. There was a statistically significant difference in TMB between low-risk and high-risk pattern tumours (P = 0.006), as well as between Pattern C tumours with and without an APOBEC signature (P = 0.002). CNA burden increased from pattern A to C.

CONCLUSION

Our findings further indicate that key molecular events in HPVA correlate with the morphologic invasive properties of the tumour and their aggressiveness. Pattern B tumours with LVI clustered with pattern C tumours, whereas pattern B tumours without LVI approached pattern A genotypically. Our study provides a biologic foundation for consolidating the Silva system into low-risk (pattern A + B without LVI) and high-risk (pattern B with LVI and pattern C) categories.

Association of Late Marriage and Low Childbirth with Cervical Cancer Screening among Korean Women: Results from a Nationwide Survey

Simple Summary

Marriage and childbirth may affect adherence to cervical cancer screening. We have examined whether marriage and childbirth were associated with the adherence to cervical cancer screening among young adult women in Korea. Among 3925 women aged 20–39 years, 39.1% undertook cervical cancer screening within two years of eligibility. Compared with unmarried women, married women were more likely to adhere cervical cancer screening (adjusted odds ratio = 2.80, 95% CI: 2.99–3.44). And, as the number of births in married women increased, the adherence to cervical cancer screening increased.

Abstract

This study aimed to identify the association of marriage and childbirth with the adherence to cervical cancer screening among young adult women. Data across four years (2017–2020) of the cross-sectional Korean National Cancer Screening Survey were used. For measuring the adherence to cervical cancer screening, we used the cervical cancer screening rate with recommendation, which was defined as the percentage of women in the population eligible for screening who have had a cervical cancer screening within the past two years. Multiple logistic regression analysis was conducted to identify the association between marriage and adherence to cervical cancer screening. Overall, 3925 women aged 20–39 years were analyzed. Of these, 39.1% were screened for cervical cancer (26.6% unmarried and 57.1% married women). The married women had significantly higher adherence to cervical cancer screening than unmarried women (adjusted odds ratio = 2.80, 95% CI: 2.99–3.44). Compared with unmarried women, adherence to cervical cancer screening was significantly more likely to increase (p for trend, <0.001) in married women with an increased number of births. Our study confirmed that marriage and childbirth influence adherence to cervical cancer screening, suggesting that unmarried women may be vulnerable to cervical cancer.

Comparative performance of various human papillomavirus assays available in Korea for detecting cervical intraepithelial neoplasia

AIM

The aim of this study was to evaluate the clinical performance for detecting cervical intraepithelial neoplasia (CIN) 2 or higher lesions among available human papillomavirus infection (HPV) genotyping tests in Korea.

METHODS

Eligible patients visited 13 tertiary hospitals for colposcopic biopsy following cervical cytology and HPV genotyping test between January and December 2018. Baseline characteristics including age, body mass index (BMI), and parity were collected from 3798 patients. The performance of the Roche Cobas HPV 4800 was evaluated against other domestic HPV assays to detect CIN2 or higher.

RESULTS

A total of seven types of HPV genotyping tests were analyzed in the research institutes. A total of 1358 patients (35.8%) tested Anyplex II HPV 28 and 701 patients (18.5%) tested Cobas 4800 HPV. The overall sensitivity in the detection of CIN2 or higher was 41.5% (38.9-44.1) in patients positive for HPV 16/18. The Cobas test for HPV 16/18 was concordant with other assays evaluated for detection of CIN2 or higher and showed sensitivity of 46.6%, which was not significantly different from other assays. Although Anyplex II HPV28 (Seegene) showed slightly decreased sensitivity for detecting CIN2 or higher lesion with HPV 16/18 positive (39.8%, p < 0.05) compared to Cobas 4800, in aspect of high-risk HPV positive, Anyplex II HPV28 showed increased sensitivity (96.9%, p < 0.05).

CONCLUSION

The performance of the HPV genotype test that were commonly used in Korea was concordant with Cobas HPV test. Further studies are needed to evaluate the safety, efficiency, and cost-effectiveness of the various commercially available domestic HPV assays.

Barriers and strategies for cervical cancer screening: What do female university students know and want?

OBJECTIVE

This study aimed to identify the distinct barriers and knowledge level of cervical cancer screening among female university students and establish intervention strategies to overcome these barriers.

METHODS

This study used a mixed-methods design with 26 female university students aged 20-29 years. We first conducted a quantitative online survey for the same study participants, divided them into three groups, and conducted focus group interviews (FGIs). Group A: participants who had sexual experience and had undergone cervical cancer screening; Group B: participants who had sexual experience and had not undergone cervical cancer screening; Group C: participants who did not have sexual experience and had not undergone cervical cancer screening.

RESULTS

The participants' ages were 21.92 ± 1.26 years. The knowledge levels for cervical cancer and screening were low to moderate. The four main themes that emerged as barriers to cervical cancer screening through the FGIs were: 1) socio-cultural barrier: conservative social perception of unmarried women's sexual life, 2) knowledge barrier: lack of knowledge and information, 3) psychological barrier: discomfort, and 4) practical barrier: time-consuming. The three themes identified for strategies were: 1) socio-cultural intervention: changing social perceptions and ensuring confidentiality, 2) educational intervention: improvement of knowledge and accessibility, and 3) alternative screening intervention: comfortable screening methods.

CONCLUSIONS

While university students' sexual experience rapidly increased, the socio-cultural perceptions of sexual health remained closed, and they had a reasonably low level of knowledge about cervical cancer screening. Therefore, various strategies sensitive to female university students' culture should be implemented to increase the knowledge level, and social efforts should be made to change the socio-cultural perception of unmarried young women's sexual health.

Clinicopathological and prognostic significance of immunophenotypic characterization of endocervical adenocarcinoma using CLDN18, CDH17, and PAX8 in association with HPV status

In 2020, the WHO published a new system for classifying invasive endocervical adenocarcinoma based on histological features and high-risk human papillomavirus (HPV) infection. However, immunophenotypes of each histological subtype require further investigation. We immunohistochemically analyzed 66 invasive endocervical adenocarcinomas using three cell-lineage-specific markers: claudin 18 (CLDN18) for gastric, cadherin 17 (CDH17) for intestinal, and PAX8 for Müllerian epithelial cells. We identified five immunophenotypes of endocervical adenocarcinoma: gastric (21%); intestinal (14%); gastrointestinal (11%); Müllerian (35%); and not otherwise specified (NOS) (20%). Adenocarcinomas with gastric immunophenotype, characterized by aging (p = 0.0050), infrequent HPV infection (p < 0.0001), concurrent lobular endocervical glandular hyperplasia (p = 0.0060), lymphovascular invasion (p = 0.0073), advanced clinical stage (p = 0.0001), and the poorest progression-free (p < 0.0001) and overall (p = 0.0023) survivals, were morphologically compatible with gastric-type adenocarcinoma of the WHO 2020 classification. Conversely, most adenocarcinomas with Müllerian (91%) and intestinal (89%) immunophenotypes were HPV associated and morphologically compatible with usual- or intestinal-type adenocarcinomas of the WHO 2020 classification. The morphology of adenocarcinomas with gastrointestinal immunophenotype was intermediate or mixed between those of gastric and intestinal immunophenotypes; 57% were HPV associated. Adenocarcinomas with NOS immunophenotype were mainly HPV associated (85%) and histologically poorly differentiated. Multivariate analysis revealed that gastric (p = 0.008), intestinal + gastrointestinal (p = 0.0103), and NOS (p = 0.009) immunophenotypes were independent predictors of progression-free survival. Immunophenotypes characterized by CLDN18, CDH17, and PAX8 exhibited clinicopathological relevance and may improve the diagnostic accuracy and prognostic value of conventional histological classification.

The incidence and survival of cervical, ovarian, and endometrial cancer in Korea, 1999-2017: Korea Central Cancer Registry

OBJECTIVE

The three major gynecologic cancers are cervical, endometrial, and ovarian cancer. This study aimed to describe the 19-year trends and survival rates in cervical, endometrial, and ovarian cancer in a Korean female population.

METHODS

We searched the Korea Central Cancer Registry to identify patients with gynecologic cancer between 1999 and 2017. Age-standardized rates and annual percent changes were calculated. The relative survival rate (RSR) was reported by histology, age, and stage for each gynecological cancer.

RESULTS

The total number of cervical, endometrial, primary peritoneal, ovarian epithelial, fallopian tube (POFT) cancer was 134,863, with the number of cases increasing every year: 6,077 in 1999 to 8,011 in 2017. The incidence of cervical cancer has decreased; however, that of POFT and endometrial cancer has increased. The 5-year RSR of cervical, POFT, and endometrial cancer was reported to be 80.8%, 61.4%, and 88.1%, respectively. In the case of cervical cancer, squamous cell carcinoma showed better survival than other histology (82.8% vs. 73.5%). Furthermore, in the case of endometrial cancer, endometrioid histology had substantially better 5-year RSR than the others (93.2% vs. 76.5%). Contrastingly, in the case of ovarian cancer, serous carcinoma had worse 5-year RSR than other types of histology.

CONCLUSION

The incidence rates for gynecologic cancers increased from 2005 to 2017, with an annual increase of 2.76 per year until 2017. Endometrial cancer had the highest RSR, while ovarian cancer had the lowest. Active cancer screening and the introduction of effective treatments might have contributed to the improved RSRs of gynecologic cancers.

Primary signet ring cell carcinoma of the uterine cervix: A case report

RATIONALE

Primary signet ring cell carcinoma of the uterine cervix is extremely rare and the clinical characteristics and prognosis are not well known and there are no specific guidelines for treatment.

PATIENT CONCERNS

A 43-year-old woman was referred to our hospital for abnormal uterine bleeding lasting 1 month.

DIAGNOSES

Histological examination revealed a signet ring cell carcinoma of the uterine cervix. After evaluation of extragenital origin, the patient was diagnosed International Federation of Gynecology and Obstetrics stage IIIC1 primary signet ring cell carcinoma or the uterine cervix.

INTERVENTION

The patient was prescribed concomitant chemo-radiation followed by intracavitary brachytherapy.

OUTCOMES

She showed no evidence of disease after treatment but, it recurred after 7 months of last treatment.

LESSONS

Different approaches to diagnosis and treatment of this rare disease are needed and molecular pathological studies related to the onset of the disease are required.

Use of micronucleus assays for the prediction and detection of cervical cancer: a meta-analysis

Cervical cancer (CC) is the fourth most common cancer in women; the survival rates depend strongly on its early detection. The Pap test is the most frequently used diagnostic tool, but due to its limited sensitivity/specificity, additional screening tests are needed. Therefore, we evaluated the use of micronucleus (MN) assays with cervical cells for the prediction and diagnosis of CC. MN reflects structural and numerical chromosomal aberrations. A search was performed in Pubmed, Scopus, Thomson ISI and Google Scholar. Subsequently, meta-analyses were performed for different grades of abnormal findings in smears and biopsies from patients which were diagnosed with CC. Results of 21 studies in which findings of MN experiments were compared with data from Pap tests show that higher MN frequencies were found in women with abnormal cells that are indicative for increased cancer risks. MN frequency ratios increased in the order inflammation (2.1) < ASC-US and ASC-H (3.3) < LGSIL (4.4) < HGSIL (8.4). Furthermore, results are available from 17 investigations in which MN were scored in smears from patients with neoplasia. MN rates increased with the degree of neoplasia [CIN 1 (4.6) < CIN 2 (6.5) and CIN 3 (10.8)] and were significantly higher (8.8) in CC patients. Our meta-analysis indicates that the MN assay, which is easy to perform in combination with Pap tests, may be useful for the detection/prediction of CC. However, standardization (including definition of the optimal cell numbers and stains) and further validation is necessary before the MN test can be implemented in routine screening.

The Expression of E6 HPV, P53 and P16ink4a at Well, Moderately, and Poorly Differentiated Cervical Adenocarcinoma

The objective of this study is to analyze the expression of E6 Humanpapilloma virus (HPV), p53, and p16INK4A in cervical adenocarcinoma grade well differentiated (WD), moderately differentiated (MD), and poorly differentiated (PD). A cross sectional study conducted at Department of Anatomic Pathology, Dr. Soetomo General Academic Hospital Surabaya Indonesia using formalin fix paraffin embedded (FFPE) from cervical normal and cervical adenocarcioma grade WD, MD, and PD. The expression of E6 HPV, p53, and p16INK4A was performed by immunohistochemistry (IHC) staining. Data were analyzed with Kruskal-Wallis and continued with Mann-Withney test. The expression of E6 HPV in the cervical adenocarcinoma showed 35.9% specimens represented negative and 64.1% specimens represented positive. There was no significant difference in the expression of E6 HPV and p53 in cervical adenocarcinoma between grade WD, MD, and PD. The p16INK4A was overexpressed, shown as diffuse appearance in 89.7% of the specimens. There was a significant difference in the expression of p16INK4A between grade WD and MD with PD. In conclusion, some of cervical adecarcinoma were not caused by infection of HPV type 16 or 18 and the expression of p16INK4A might take a role in the developing of malignancy that caused by infection of HPV.

Effect of Pap smear screening on cervical cancer stage at diagnosis: results from the Korean National Cancer Screening Program

OBJECTIVE

We aimed to determine the differences in stage at diagnosis of cervical cancer among Korean women according to screening history.

METHODS

Using linkage data from the Korean Central Cancer Registry and Korean National Cancer Screening Program (KNCSP), we included 18,388 women older than 30 years who were newly diagnosed with cervical cancer between 2013 and 2014 and examined their screening history. Between individuals, age group and socioeconomic status were matched to control for potential confounders.

RESULTS

Significantly more cases of carcinoma in situ (CIS) were diagnosed in the ever-screened (71.77%) group than in the never-screened group (54.78%), while localized, regional, distant, and unknown stage were more frequent in the never-screened group. Women in the ever-screened group were most likely to be diagnosed with CIS than with invasive cervical cancer (adjusted odds ratio [aOR]=2.40; 95% confidence interval [CI]=2.18-2.65). The aOR for being diagnosed with CIS was highest among women who were screened 3 times or more (aOR=5.10; 95% CI=4.03-6.45). The ORs were highest for women screened within 24 months of diagnosis and tended to decrease with an increasing time since last screening (p-trend <0.01).

CONCLUSION

The KNCSP for cervical cancer was found to be positively associated with diagnosis of cervical cancers at earlier stages among women aged 30 years or older. The benefit of screening according to time was highest for women screened within 24 months of diagnosis.

Trend analysis of process quality indicators for the Korean National Cervical Cancer Screening Program from 2005 to 2013

Objective

This study sought to examine changes in trends for quality indicators of the population-based Korean National Cancer Screening Program (KNCSP) for cervical cancer from years 2005 to 2013.

Methods

Our study data were derived from the KNCSP database. Cervical cancer diagnosis information was ascertained through linkage with the Korean National Cancer Registry and the KNCSP database. Performance measures for cervical cancer screening were estimated, including participation rate, positive rate, crude detection rate (CDR), interval cancer rate (ICR), positive predictive value (PPV), sensitivity, and specificity. Joinpoint analysis was applied to calculate annual percentage changes (APCs) in all indicators according to socio-demographic factors.

Results

A significant increasing trend was noted in participation rates (APC=13.4%; 95% confidence interval [CI]=10.5, 16.4). PPV and specificity increased from years 2005 to 2009 and remained stable till 2013. An increasing trend was discovered in CDRs for cervical cancer in situ (APC=3.9%; 95% CI=1.0, 6.9), whereas a decreasing trend was observed in ICRs for invasive cervical cancer (APC=−2.5%; 95% CI=−4.5, −0.5). Medical Aid recipients and women older than 70 years showed the lowest participation rates, but higher CDRs and ICRs, compared to other groups. In general, most of the quality indicators for cervical cancer screening improved from 2005 to 2009 and remained stable to 2013.

Conclusion

The KNCSP for cervical cancer in Korea has improved in terms of participation rate and accuracy of the screening test. These results may be attributed to the National Quality Improvement Program for KNCSP.

circEYA1 Functions as a Sponge of miR-582-3p to Suppress Cervical Adenocarcinoma Tumorigenesis via Upregulating CXCL14

Circular RNAs (circRNAs) function as efficient microRNA (miRNA) sponges that regulate gene expression in the pathogenesis of many human malignancies. However, their roles in cervical adenocarcinoma remain largely unknown. In this study, we aimed to seek novel circRNAs that regulate cervical adenocarcinoma carcinogenesis and to explore their regulatory mechanisms as well as clinical significance. We identified that 24 circRNAs were differentially expressed in cervical adenocarcinoma tissues by RNA sequencing. Among them, circEYA1 was the most significantly downregulated circRNA in cervical adenocarcinoma. In cervical adenocarcinoma cells, circEYA1 overexpression led to suppression of cell viability and colony formation, promotion of apoptosis, and a decrease of the xenograft tumor growth. The mechanism underlying these observations is that circEYA1 functioned as a sponge of miR-582-3p and abrogated its suppression of CXCL14 expression. Consistently, miR-582-3p inhibition phenocopied the biological effects of circEYA1 overexpression in cervical adenocarcinoma cells. Moreover, miR-582-3p overexpression reversed the suppressive behaviors of circEYA1 in vitro and in vivo. In addition, the expression, correlation, and clinical diagnostic value of circEYA1/miR-582-3p/CXCL14 were confirmed in 198 clinical cervical tissue samples. In summary, our findings highlight a novel tumor suppressive role of circEYA1 in cervical adenocarcinoma tumorigenesis and may provide a potential diagnostic marker and therapeutic target for patients with cervical adenocarcinoma.

Expression of alpha-methylacyl-CoA racemase in vaginal gastric-type adenocarcinoma and uterine clear cell carcinoma

Background

Alpha-methylacyl-coenzyme A racemase (AMACR, P504S) is a commonly used marker in immunohistochemical diagnosis of prostate cancer. Recent studies identified P504S markers of the clear cell histotype in the ovary and/or endometrium. Gastric-type adenocarcinoma (GAS) is difficult to diagnose histologically, particularly when there is crossover with clear cell carcinoma (CCC). However, the significance of P504S for differentially diagnosing GAS and CCC is unclear.

Aim

To evaluate P504S as a potential diagnostic marker of GAS and CCC.

Settings and Design

We analyzed P504S expression in 48 cervical carcinomas (32 GAS and 16 CCC), as well as the expression of other markers including hepatocyte nuclear factor-1 beta (HNF-1β) and NapsinA.

Material and Methods

The expression differences of HNF-1β, NapsinA, and P504S in GAS and CCC were detected by immunohistochemistry. Immunohistochemical histoscores based on the intensity and extent of staining were calculated.

Results

The positive rates of HNF-1β in GAS and CCC were 90.32% and 75%, respectively. (χ2 = 2.251, P = 0.663). The positive rates of NapsinA in GAS and CCC were 19.36% and 81.25%, respectively. (χ2 = 47.332, P < 0.01). The positive rates of P504S in GAS and CCC were 16.13% and 81.25%, respectively. (χ2 = 41.420, P < 0.01). HNF-1β was frequently expressed in GAS and CCC, while NapsinA and P504S were frequently expressed in CCC, and reduced or lost in GAS.

Conclusion

NapsinA and P504S can be used to differentiate between GAS and CCC.

The Burden of Cervical Cancer in Korea: A Population-Based Study

This study used the Korean National Health Insurance (NHI) claims database from 2011 to 2017 to estimate the incidence and the incidence-based cost of cervical cancer and carcinoma in situ of cervix uteri (CIS) in Korea. The primary outcome was the direct medical cost per patient not diagnosed with cervical cancer (C53) or CIS (D06) 2 years prior to the index date in the first year after diagnosis. A regression analysis was conducted to adjust for relevant covariates. The incidence of cervical cancer tended to decrease from 2013 to 2016, while that of CIS increased. In particular, the incidence rate of CIS in women in their 20 s and 30 s increased by 56.8% and 28.4%, respectively, from 2013 to 2016. The incidence-based cost of cervical cancer and CIS was USD 13,058 and USD 2695 in 2016, respectively, which increased from 2013. Multivariate regression analysis suggested that age was the most influential variable of the cost in both patient groups, and the cost was highest in those aged over 60, i.e., the medical cost was significantly lower in younger women than their older counterparts. These findings suggest that targeting younger women in cervical cancer prevention is a reasonable option from both economic and public health perspectives.

Incidence of Cervical, Ovarian and Uterine Cancer in Eritrea: Data from the National Health Laboratory, 2011-2017

The main objective of this study was to investigate the incidence of cervical (C53), ovarian (C56) and uterine (C54-55) cancers in pathology department of the National Health Laboratory of Eritrea between 2011 and 2017. All tumour positive cases from cervix, ovary and uterus diagnosed between 2011 and 2017 were analyzed, based on the data from the pathology department available in National Health Laboratory. We summarized the results by using crude incidence rates (CIR) and age-standardized rates (ASRs). Annual percentage changes (APCs) for each site were calculated and compared according to ten-year age difference and year of occurrence. Between 2011 and 2017, 883 cases of cervical, ovarian and uterine tumours were reported in Eritrea. Malignant and benign tumours/entities comprising 269 and 614, respectively. The ASR for malignant tumours was highest in women aged between 60-69 (6.84 per 100 000). Total ASR for specific gynecological cancers (cervical, ovarian, uterine) was 19.32 per 100 000 females. The ASR for cervical cancer over the study period was 8.7 per 100 000. The ASR for ovarian and uterine cancers were 6.75 per 100 000 and 5.14 per 100 000, respectively. Over the study period, the incidence of these cancers was largely stable with no significant change in incidence rates recorded. In sum, the ASR for cervical cancer is relatively low compared to the rates reported in the region. Further, the ASR for ovarian and uterine cancers is nearly similar to the rates observed in this region. The study also provides ample evidence on the need for research targeted at uncovering the true burden of gynecological cancers in Eritrea. Potential solutions will require the establishment of high-quality population-based cancer registries (PBCRs) and long-term commitment to improvements in research platforms, training, screening, diagnosis, and the overall management of cancers in the country.

Prevalence of human papillomavirus-related diseases in the Republic of Korea: a cross-sectional study

OBJECTIVE

We aimed to evaluate trends in the prevalence of human papillomavirus (HPV)-related diseases in the era before the introduction of organised HPV vaccination programmes in the Republic of Korea.

METHODS

This cross-sectional study used National Health Insurance Service data from 2002 to 2015 and included participants who were diagnosed with the following HPV-related diseases (codes from the International Classification of Diseases, 10th Revision): genital warts (A63.0); cancer in the head and neck (C00-C10), anus (C21), vulva (C51), vagina (C52), cervix uteri (C53) and penis (C60); carcinoma in situ (CIS) of the lip/oral cavity/pharynx (D00.0), anus (D01.3), cervix (D06), vulva (D07.1), vagina (D07.2) and penis (D07.4); benign neoplasms of the larynx (D14.1); and dysplasia of the cervix (N87), vagina (N89) and vulva (N90). For each diagnosis, the fraction of cases attributable to HPV in Korea was assessed based on the percentages of diseases attributable to HPV reported in some international studies. The age-standardised prevalence was estimated using the direct population-based method.

RESULTS

The overall age-standardised prevalence of HPV-related diseases increased from 2002 to 2015, mainly due to increased prevalence of genital warts in men and cervical dysplasia and CIS in women. In women, genital wart prevalence increased from 2002 (24.4 per 100 000) to 2011 (57.1) and then decreased until 2015 (53.5); in men, the prevalence increased steadily from 2002 (22.9) to 2015 (109.4). The prevalence of cervical dysplasia and CIS increased (from 86.5 in 2002 to 484.5 in 2015, and from 60.3 in 2002 to 114.9 in 2015, respectively), but that of cervical cancer decreased (from 120.0 in 2002 to 106.9 in 2015).

CONCLUSIONS

Non-organised HPV vaccination and organised cervical cancer screening may have contributed to the downward trend in genital wart prevalence and the upward trend in cervical abnormalities among women.

Burden of Human papillomavirus (HPV)-related disease and potential impact of HPV vaccines in the Republic of Korea

Background

We aimed to review the burden and the potential impact of human papillomavirus (HPV) vaccines on HPV-related diseases in the Republic of Korea and to discuss cervical cancer prevention practices in this country.

Methods

Cancer burden statistics were retrieved from GLOBOCAN-2018 and Statistics Korea. HPV disease burden was assessed via systematic review. Vaccine types relative contribution (RC) was estimated using data from an international project using formalin-fixed paraffin-embedded specimens.

Results

Despite a downtrend in cervical cancer in recent years, Korean rates remain high. In contrast, oropharyngeal cancer incidence has gradually increased and other anogenital cancers remain rare.

In Korea, HPV prevalence in general population is around 20%. In cervical cancer, RC of HPVs 16/18 (74.0%) increased to 92.0% when including HPVs 31/33/45/52/58. Limited information was available for other HPV-related cancer sites.

Regarding prevention, since the inclusion of the HPV vaccine into the National Immunization Program, almost half (49%) of the target cohort in 2016 had received the first dose of vaccine. Further, percentage of women screened with pap has increased from 41.1%-2009 to 53.0%-2016.

Conclusions

HPV-related disease burden in Korea is significant. Results suggest that the combination of effective and high coverage HPV vaccination and screening programmes could substantially impact on HPV-related disease in Korea.

•

HPV-related disease burden (cancer and genital warts) in Korea is significant.

•

HPV16 is the most frequent genotype, causing itself more than 60% of HPV-related cancers.

•

HPV vaccine types 16/18/31/33/45/52/58/6/11 cause 92.0% of cervical cancers.

•

HPV vaccines could significantly impact on the HPV-related disease burden.

The economic burden of human papillomavirus infection-associated diseases in the Republic of Korea, 2002-2015

BACKGROUND

This prevalence-based, cost-of-illness study estimated the health care costs of human papillomavirus (HPV) infection-associated diseases in the era before the introduction of organized HPV vaccination for 12-year-old girls in 2016, South Korea.

METHODS

The claims data provided by the National Health Insurance Service was used to estimate the prevalence of HPV-associated diseases and their direct medical costs, including costs related to hospitalizations, outpatient visits, and medications.

RESULTS

A total of 1.3 million men and women used medical services for HPV-attributed diseases between 2002 and 2015. Among women, the most common diseases attributable to HPV were cervical dysplasia (64.4%), anogenital warts (12.9%), cervical carcinoma in situ (10.7%) and cervical cancer (2.6%), whereas anogenital warts (80.6%), benign neoplasms of larynx (14.3%), and anal cancers (8.9%) were most common among men. In 2015, the healthcare cost attributable to HPV was 124.9 million US dollars (USD) representing 69.0% of the annual cost of all HPV-associated diseases. At a cost of 75.1 million USD, cervical cancer contributed the largest economic burden in 2015 followed by cervical dysplasia (19.4 million USD) and cervical carcinoma in situ (10.7 million USD). These three conditions represented 58.2% of the total annual cost of all HPV-associated diseases, while 84.2% of the total annual cost was attributable to HPV. Annual health care costs increased from 42.6 million USD in 2002 to 180.9 million USD in 2015.

CONCLUSION

The healthcare costs associated with HPV-related diseases in Korea are substantial and increased between 2002 and 2015 mainly caused by increased number of patients. Expanding the target age for HPV vaccination of girls and introducing HPV vaccination for boys are possible ways of reducing the economic burden of HPV-associated disease and should be considered.

A prospective pilot evaluation of vaginal and urine self-sampling for the Roche cobas 4800 HPV test for cervical cancer screening

This pilot study sought to evaluate the feasibility of utilizing vaginal self-swabs and urine samples for HPV-based cervical cancer screening in 700 women who had undergone conventional Pap smear screening via the national cervical cancer program in Korea. The cobas 4800 HPV test was utilized to detect HPV in the self-samples. Pap smear results revealed three cases of atypical squamous cells of undetermined significance, 649 cases of negative for an intraepithelial lesion or malignancy, and 48 non-specific inflammatory findings. High-risk HPV was detected in 6.7% of urine samples and 9.6% of vaginal self-swab samples. The overall agreement for HPV 16/18 between urine and vaginal self-swab samples was 99.1% (95%CI 98.1% to 99.6%). Colposcopic biopsy revealed one cervical intraepithelial neoplasia (CIN) 3 lesion, 12 CIN1 lesions, and 23 normal or chronic cervicitis lesions. In conclusion, urine and vaginal self-swab sampling was feasible and deemed a potential alternative for HPV detection in women who hesitate to participate in cervical cancer screening programs. Meanwhile, due to overall lower rates of abnormal cytology and sexual risk behaviors in Korea, a larger sample size than expected is needed to assess the sensitivity of CIN2+ detection via self-samples.

Updates on Cancer Epidemiology in Korea, 2018

Cancer is a major cause of morbidity and the most common cause of death in Korea. There are currently approximately 200,000 incident cancer cases and 78,000 individuals die from cancer every year. The factors directly related to cancer incidence, including aging, smoking, obesity, and Westernized dietary habits, have been increasing during the past several decades. Since 1999, trends toward increased incidence have been observed for thyroid, breast (in women), colorectal, and prostate cancer. Currently, these trends have changed direction, and the incidence of stomach and liver cancer in both sexes, and cervical cancer in women have continually declined. Although the number of cancer deaths increased by a factor of 2.7 from 1983 to 2016, the age-standardized mortality associated with cancer has been decreasing by 3% every year. The 5-year relative survival rate (RSR) has also improved over the past several decades, especially for stomach, prostate, and breast cancer, which had 5-year RSRs greater than 90% in the most recent report.

Nationwide cervical cancer screening in Korea: data from the National Health Insurance Service Cancer Screening Program and National Cancer Screening Program, 2009-2014

OBJECTIVE

The rates of participation in the Korean nationwide cervical cancer screening program and the rates of abnormal test results were determined.

METHODS

The database of the National Health Insurance Service (NHIS) was used during the study period (2009-2014).

RESULTS

The participation rate increased from 41.10% in 2009 to 51.52% in 2014 (annual percentage change, 4.126%; 95% confidence interval [CI]=2.253-6.034). During the study period, women ≥70 years of age had the lowest rate of participation (range, 21.7%-31.9%) and those 30-39 years of age the second-lowest (27.7%-44.9%). The participation rates of National Health Insurance beneficiaries (range, 48.6%-52.5%) were higher than those of Medical Aid Program (MAP) recipients (29.6%-33.2%). The rates of abnormal results were 0.65% in 2009 and 0.52% in 2014, with a decreasing tendency in all age groups except the youngest (30-39 years). Every year the abnormal result rates tended to decrease with age, from the age groups of 30-39 years to 60-69 years but increased in women ≥70 years of age. The ratio of patients with atypical squamous cells of undetermined significance compared with those with squamous intraepithelial lesions increased from 2.71 in 2009 to 4.91 in 2014.

CONCLUSION

Differences related to age and occurring over time were found in the rates of participation and abnormal results. Further efforts are needed to encourage participation in cervical cancer screening, especially for MAP recipients, elderly women and women 30-39 years of age. Quality control measures for cervical cancer screening programs should be enforced consistently.

Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion triage in Korean women: Revisiting the 2012 American Society of Colposcopy and Cervical Pathology screening guidelines

Objective

To determine whether triage for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) from the updated American Society for Colposcopy and Cervical Pathology cervical cancer screening guidelines is applicable in Korean women.

Methods

We investigated women with ASC-US or LSIL including referred from local hospitals visited for cervical cancer screening at Korea University Guro Hospital from February 2004 to December 2014. Detailed information on the results of Papanicolaou (Pap) smears, human papillomavirus (HPV) DNA tests, and cervical biopsies were collected through chart review. Cervical biopsy results were compared in eligible women according to individual Pap smear findings and HPV DNA status.

Results

Of 216,723 possible cases, 3,196 were included. There were 212 (6.6%) women with ASC-US and 500 (15.6%) with LSIL. The risk of ≥cervical intraepithelial neoplasia (CIN) 2 was significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (93.3% vs. 6.7% and 96.7% vs. 3.3%, P<0.001 and P<0.001, respectively). The risk of ≥CIN 3 was also significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (97.0% vs. 3.0% and 93.0% vs. 7.0%, P<0.001 and P<0.001, respectively). Age-stratified analysis revealed that more CIN 2 or CIN 3 was diagnosed in women aged 30 to 70 with ASC-US or LSIL when HPV DNA was present.

Conclusion

Observation with Pap and HPV DNA tests rather than immediate colposcopy is a reasonable strategy for ASC-US or LSIL when the HPV DNA test is negative, especially in women aged 30 to 70. Reflection of these results should be considered in future Korean screening guidelines.

Validity of self-reported cancer history in the health examinees (HEXA) study: A comparison of self-report and cancer registry records

PURPOSE

To assess the validity of the cohort study participants' self-reported cancer history via data linkage to a cancer registry database.

METHODS

We included 143,965 participants from the Health Examinees (HEXA) study recruited between 2004 and 2013 who gave informed consent for record linkage to the Korean Central Cancer Registry (KCCR). The sensitivity and the positive predictive value of self-reported histories of cancer were calculated and 95% confidence intervals were estimated.

RESULTS

A total of 4,860 participants who had at least one record in the KCCR were included in the calculation of sensitivity. In addition, 3,671 participants who reported a cancer history at enrollment were included in the calculation of positive predictive value. The overall sensitivity of self-reported cancer history was 72.0%. Breast cancer history among women showed the highest sensitivity (81.2%), whereas the lowest sensitivity was observed for liver cancer (53.7%) and cervical cancer (52.1%). The overall positive predictive value was 81.9%. The highest positive predictive value was observed for thyroid cancer (96.1%) and prostate cancer (96.1%), and the lowest was observed for cervical cancer (43.7%).

CONCLUSION

The accuracy of self-reported cancer history varied by cancer site and may not be sufficient to ascertain cancer incidence, especially for cervical and bladder cancers.

Cervical Adenocarcinoma Has a Poorer Prognosis and a Higher Propensity for Distant Recurrence Than Squamous Cell Carcinoma

Objective

We aimed to analyze the differences in prognosis and the pattern of recurrence between squamous cell carcinoma (SCC) and adenocarcinoma (ADC) in patients with cervical cancer.

Methods

We retrospectively reviewed the medical records of 969 patients with SCC and 144 patients with ADC who underwent radical hysterectomy and pelvic lymph node dissection at the Busan Paik Hospital between January 1988 and December 2010.

Results

Adenocarcinoma was associated with poorer disease-free survival (P = 0.0515) and overall survival (OS) (P = 0.0156) compared with SCC, and that this was more apparent for patients with International Federation of Gynecology and Obstetrics stages IIA to IIB disease. Subgroup analysis by prognostic factors for recurrence showed significant differences in the OS in the intermediate-risk subgroup (P = 0.0266), but not in the high-risk subgroup (P = 0.1674). Based on the metastatic pattern in patients with recurrence, ADC was associated with an increased risk for distant recurrence resulting from hematogenous spread compared with SCC (P < 0.0001), and patients with distant recurrence showed a worse OS (P = 0.0481) and survival after recurrence (P = 0.0016) than patients with locoregional or lymphatic recurrence. Multivariate analysis showed that ADC was a significant independent factor for poor disease-free survival (P = 0.0034) and OS (P = 0.0001).

Conclusions

Adenocarcinoma is associated with a poorer prognosis and a greater probability of distanat recurrence compared with SCC. Different therapeutic strategies for ADC need to be developed, and when considering the greater tendency for distant recurrence in patients with ADC, systemic chemotherapy may have a role in reducing the risk of hematogenous spread.

Projected impact of HPV vaccination and primary HPV screening on cervical adenocarcinoma: Example from Australia

Cytology-based cervical screening appears to have had a limited effect on the incidence of adenocarcinoma, however HPV vaccination and HPV-based screening will likely play a role in reducing future burden. Using Australia as an example, we estimated the future burden (2015-2040) of adenocarcinoma in the absence of other interventions; and the impact of HPV vaccination (introduced 2007) and HPV-based screening (commencing 2017). Future burden was estimated considering underlying trends in adenocarcinoma, using national data (1982-2010). The relative reduction in adenocarcinoma due to HPV vaccination and HPV-based screening was derived from observed clinical data. Adenocarcinoma incidence rates have been increasing since the early-mid 2000s (average annual increases from 3.0%(25-49 years) -8.1%(20-24 years)). If these trends continue, rates would increase from 1.4 to 2.4/100,000 in <50 years and from 2.2 to 4.4/100,000 in 50+ years by 2040. Taking into account coverage, HPV vaccination will reduce 2040 incidence by 36-39%, mainly in women <50 years (61% reduction). Taking into account uncertainties in trends and screening effectiveness, HPV-based screening will reduce incidence by an additional 19-43%, mainly in women 50+ years (additional 30-68% reduction). Together, these interventions will reduce incidence by 55-81%.

Common Causes of Postmenopausal Bleeding in Korean Women: 10-Year Outcomes from a Single Medical Center

The common causes of postmenopausal bleeding (PMB), according to the data from the western world, are atrophy, hormone replacement therapy (HRT), endometrial cancer, etc. We conducted a retrospective study to assess whether the causes of PMB in Korean postmenopausal women are similar to those already known. This retrospective study used 10-year medical records (March 2005 to December 2014) of 792 PMB women in the Yonsei University Health System. The data were divided into 2 categories by 5-year intervals to compare the differences between the 2 periods. The most common cause of PMB in Korean women was atrophy (51.1%). Polyps and HRT were the second, followed by anticoagulant medications, cervical cancer, and endometrial cancer. The proportion of patients with cervical cancer significantly decreased during the second half of the decade (8.7% vs. 5.2%; P = 0.048). Although no significant change was noted for HRT, its rank was higher during the latter 5-year period. Only the most common cause of PMB was the same as the conventional data. Interestingly, the proportion of patients with cervical cancer decreased during the latter half of the decade, reflecting the changes in the nation's cancer prevalence rate, while the use of HRT increased.

Increasing incidence of invasive and in situ cervical adenocarcinoma in the Netherlands during 2004-2013

In the developed world, the incidence of cervical squamous cell carcinoma has decreased, however, the incidence of adenocarcinoma in situ (AIS) and invasive adenocarcinoma increased, predominantly in young females. The goal of this study was to evaluate the most recent incidence rates of AIS, adenocarcinoma, and squamous cell carcinoma of the uterine cervix in the Netherlands in 2004-2013. By using Dutch national pathology and cancer registries, we calculated European standardized incidence rates (ESR) and estimated annual percentage changes (EAPC) for AIS during 2004-2013 and for invasive cervical carcinomas during 1989-2013. For AIS, presence or absence of concomitant cervical intraepithelial neoplasia (CIN) was explored. The estimated annual percentage change (EAPC) of squamous cell carcinoma decreased significantly in 1989-2013, predominantly in 1989-2003. The EAPC of invasive adenocarcinoma decreased in 1989-2003, but remained stable in 2004-2013. The EAPC of AIS increased significantly, predominantly in women of 25-39 years old. Of these AIS cases, 58.9% had concomitant CIN and AIS with concomitant CIN showed a significantly higher EAPC compared to AIS without CIN. Our conclusion is that despite a nationwide screening program for cancer of the uterine cervix, the incidence of adenocarcinoma in the Netherlands remained stable during 2004-2013 and the incidence of adenocarcinoma in situ increased. This was most predominant in cases with concomitant CIN and in younger females. The incidence of squamous cell carcinoma decreased in the same timeframe.

Factors Associated with Delayed Reporting of Invasive Carcinoma Cervix in a Rural Tertiary Care Center

BACKGROUND

The delay in detection of premalignant and malignant lesions can have an adverse impact on the outcome of carcinoma cervix. In spite of relatively good healthcare facilities, women in Kerala continue to report in advanced stages of cervical malignancy.

OBJECTIVE

To analyze factors associated with delayed reporting and to evaluate awareness about screening and vaccination programs for prevention of carcinoma cervix.

METHOD

A cross-sectional study design was used to evaluate the subjects diagnosed to have carcinoma cervix in the outpatient Department of Obstetrics and Gynecology, Government Medical College, Thrissur, Kerala for a period of two years. One-hundred and fifteen women diagnosed to have invasive carcinoma during the study were evaluated. Data analysis was done and expressed as means and percentages.

RESULTS

One-hundred and fifteen women participated in the study. Only 26 (21.7 %) of the subjects were diagnosed in a relatively early stage, i.e., up to stage 2a. Most of them were from families living below poverty line (63.9 %) and were either widowed or divorced (57.3 %). Illiteracy was common (48.9 %) among them, and many (71.3 %) worked as manual laborers. None of the subjects was aware about the availability of screening and vaccination programs for prevention of carcinoma cervix.

CONCLUSIONS

There is a wide gap between the awareness of availability of healthcare and its proper utilization by the poor. Scaling up of public awareness of preventive programs and the availability of healthcare facilities are essential to enable the timely utilization of such services to facilitate early detection of invasive carcinoma cervix.

Trends and Age-Period-Cohort Effects on the Incidence and Mortality Rate of Cervical Cancer in Korea

PURPOSE

This study was conducted to describe the trends and age-period-cohort effects on the incidence and mortality rate of cervical cancer in Korea.

MATERIALS AND METHODS

The incidence and mortality rate of cervical cancer among ≥ 20-year-old women from 1993 to 2012 were obtained from the Korea Central Cancer Registry and the Korean Statistical Information Service. Age-standardized rates were calculated and Joinpoint regression was used to evaluate the trends in the incidence and mortality rate. Age-period-cohort analysis was performed to investigate the independent effects of age, period and cohort.

RESULTS

The incidence of cervical cancer decreased from 32.8 per 100,000 in 1993 to 15.9 per 100,000 in 2012 (annual percent change [APC], -3.9%; 95% confidence interval [CI], -4.2% to -3.6%). The mortality rate decreased from 5.2 per 100,000 in 1993 to 2.1 per 100,000 in 2012 (APC, -4.8%; 95% CI, -5.1% to -4.4%); however, the incidence and mortality rates among young women (< 30 years old) increased. An age-period-cohort model of the incidence and mortality rate showed decreasing period effects between 1993 and 2008 and decreasing cohort effects between 1928 and 1973, while birth cohorts after 1973 exhibited slight increases in the incidence and mortality rate of cervical cancer.

CONCLUSION

Recent decreases in the incidence and mortality rate of cervical cancer were due to decreases in the period and cohort effects, which reflect the implementation of a cancer screening program and changes in lifestyle. However, our findings also highlighted an increase in cohort effects on the incidence and mortality rate among young women born after 1973.

Knowledge of HPV and Surgery among Women Who Underwent Cervical Conization: A Korean Multi-Center Study

PURPOSE

Human papillomavirus (HPV) infection is a well-known cause of cervical cancer, which, along with its precursors, can be diagnosed and treated with cervical conization (CC). This study aimed to assess HPV- and procedure-related knowledge among women who had undergone CC.

MATERIALS AND METHODS

Between February and May 2014, consecutive women who had undergone CC at five different educational hospitals were recruited. All patients had undergone a loop electrosurgical excision procedure as the method of CC. A survey was conducted with a self-developed, 29-item questionnaire, measuring knowledge related to HPV and CC. We analyzed the responses of 160 patients who completed the questionnaire.

RESULTS

Mean total knowledge scores (±standard deviation) for HPV and CC were 5.2±3.0 of a possible 13.0 and 8.3±4.2 of a possible 16.0, respectively. While 73% of the patients knew that HPV is the main cause of cervical cancer, only 44% knew that HPV is sexually transmitted. The purpose of CC was correctly identified by 71% of the patients. However, 35% failed to indicate the anatomical area resected at the time of CC in the schematic diagram. Women who were younger (p<0.001), had higher education level (p<0.001), and higher family income (p=0.008) had higher knowledge scores. In contrast, neither interval from CC to survey nor disease severity were associated with total knowledge score.

CONCLUSION

The level of knowledge related to HPV and CC was unexpectedly low in women who had undergone CC. Intuitive educational resources may improve this knowledge, and further cohort studies are warranted.

Health Behaviors and Associated Sociodemographic Factors in Cervical Cancer Survivors Compared with Matched Non-Cancer Controls

We explored the prevalence of smoking, alcohol consumption, physical activity, and obesity in cervical cancer survivors and examined associations between sociodemographic factors and each health behavior. We studied 448 cervical cancer survivors ≥2 years after their initial diagnosis who had completed treatment. The total sample consisted of these survivors, and 4,480 cancer-free controls who were grouped into 5-year age cohorts and matched to the survivors in terms of both education and monthly household income. The prevalence of current smoking, current alcohol consumption, physical inactivity, and obesity in cervical cancer survivors (2.68, 23.88, 62.02, and 32.81%, respectively) did not differ significantly from those of matched non-cancer controls. Age (younger), marital status (married), and education (≥college) were associated with lower probabilities of current alcohol consumption (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.88–0.95; OR = 0.42, 95% CI = 0.23–0.78; OR = 0.49, 95% CI = 0.25–0.97, respectively). A monthly household income ≥$2,000, being employed, and self–rated health status (less healthy) were associated with physical inactivity (OR = 0.61, 95% CI = 0.37–0.99; OR = 2.16, 95% CI = 1.36–3.42; OR = 1.94, 95% CI = 1.23–3.05, respectively). Both age and number of years since diagnosis were associated with obesity (OR = 1.04, 95% CI = 1.01–1.08; OR = 0.38; 95% CI = 0.20–0.72, respectively). The health behaviors of cervical cancer survivors did not differ from those of matched cancer-free controls. As health behaviors are modifiable, identification of cervical cancer survivors who are at risk of an unhealthy lifestyle would allow individual- and population-based intervention programs to more effectively use their limited resources.

Overall accuracy of cervical cytology and clinicopathological significance of LSIL cells in ASC-H cytology

OBJECTIVE

The aims of this study were (i) to investigate the diagnostic accuracy of Papanicolaou (Pap) smears and (ii) to evaluate the clinicopathological significance of the presence of low-grade squamous intraepithelial lesion (LSIL) cells in atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H) cytology.

METHODS

We retrospectively reviewed paired cytological and histological findings from 3141 patients. ASC-H cytology was classified as either ASC-H or LSIL with some features suggestive of the presence of a concurrent HSIL (LSIL-H). Clinicopathological characteristics were evaluated through a retrospective study and meta-analysis.

RESULTS

The accuracy of the cytological diagnosis was 93.7% (2942 of 3141 cases). The positive predictive value (PPV) of ASC-H for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+ ) was 51.4%. In cases of LSIL-H, CIN 2+ histology was more prevalent in the pre-menopausal period (19-44 years) than in peri- and postmenopausal periods (older than 45 years) (P = 0.024). There was no difference in the ability of LSIL-H and ASC-H to predict CIN 2+.

CONCLUSION

The Pap smear is a good cervical cancer screening method. Although there was no difference in the predictive value for CIN 2+ between LSIL-H and ASC-H, the presence of definite LSIL cells was more predictive of CIN 2+ in younger patients than in older patients.

Clinical parameters associated with absence of endocervical/transformation zone component in conventional cervical Papanicolaou smears

OBJECTIVE

To study clinical factors predicting the absence of endocervical/transformation zone (EC/TZ) components of conventional cervical Papanicolaou (Pap) smears.

MATERIALS AND METHODS

The medical charts of patients who received Pap smears between March 2006 and August 2006 in the hospital were reviewed. The results of their Pap smears were retrieved while their demographic and clinical information were obtained from the medical charts. After excluding 378 cases with incomplete demographic data and 1397 cases with a history of pelvic irradiation, pelvic malignancy, and hysterectomy, 5662 cases were enrolled for data analysis. The relationship between clinical parameters and the absence of EC/TZ component was analyzed by Pearson Chi-square tests with Yates continuity correction and binary logistic regression tests.

RESULTS

The incidence of satisfactory but absence of EC/TZ component was 8.7% (491/5662). Pregnancy increased the absence of EC/TZ component [odds ratio (OR}: 2.84, 95% confidence interval (CI): 2.14-3.77, p<0.0001]. Postpartum status and endocervical polyps decreased incidence (OR: 0.61, 95% CI: 0.38-0.98, p = 0.043 and OR: 0.33, 95% CI: 0.25-0.44, p<0.0001, respectively).

CONCLUSIONS

Pregnancy is the only clinical factor associated with increased incidence of absence of EC/TZ cells. For these pregnant women undergoing a Pap smear, a more effective strategy may be needed to get a satisfactory smear with adequate EC/TZ components.

Prognosis of Cervical Cancer in the Era of Concurrent Chemoradiation from National Database in Korea: A Comparison between Squamous Cell Carcinoma and Adenocarcinoma

In 1999, the National Cancer Institute issued a clinical advisory strongly touting the advantage of cisplatin-based chemoradiation (CCRT) for cervical cancer patients requiring radiation for their treatment. This study aimed to compare survival outcomes of cervical squamous cell carcinoma and adenocarcinoma before and after the advent of CCRT. Data were obtained from the Korea National Cancer Incidence Database for patients who were diagnosed with cervical cancers between 1993 and 2012. We compared survival according to histologic subtypes in cervical cancer patients diagnosed before (1993–1997), during (1998–2002), and after (2003–2012) the introduction of CCRT. A total of 80,766 patients were identified, including 64,531 (79.9%) women with squamous cell carcinomas and 7,265 (9.0%) with adenocarcinoma. With the introduction of CCRT, survival trends gradually increased in patients of both histologic subtypes with regional tumors. However, survival was significantly higher in squamous cell carcinoma than in adenocarcinoma patients regardless of treatment modalities (surgery alone, P < 0.001; surgery followed by CCRT, P < 0.001; or primary CCRT, P = 0.003). Multivariate analysis showed that adenocarcinoma was an independent negative prognostic factor for survival regardless of the time period (before CCRT, hazard ratio (HR) = 1.49; 95% confidence interval (CI), 1.37–1.62; after introduction of CCRT, HR = 1.40; 95% CI, 1.30–1.50). Although the survival of adenocarcinoma has improved after the introduction of CCRT, adenocarcinoma is still associated with worse overall survival compared to squamous cell carcinoma in the era of CCRT.

Autophagy knocked down by high-risk HPV infection and uterine cervical carcinogenesis

Cervical cancer is a leading cause of cancer death among women in the world. The specific etiopathogenesis of cervical cancer is indeed complex. Even so, we should make arduous efforts to have a precise understanding of the complicate cellular/molecular mechanisms underlying initiation, progression and/or prevention of the cervical cancer. The high-risk human papillomavirus (hrHPV) is considered as the major causative agent of cervical cancer. But with the existence of hrHPV only is not sufficient, autophagy plays a vital character in the development of cervical cancer. Autophagy is the endogenous, tightly regulated cellular "housekeeping" process responsible for the degradation of damaged and dysfunctional cellular organelles and protein aggregates. Our aims in this review were (1) to provide a brief synopsis of process of autophagy (including an overview of the key molecular mediators of this catabolic process and its relationship with hrHPV infection) and (2) most importantly, summarize the current evidence for autophagy-mediated cervical carcinogenesis. One of the latest opinions about the etiopathogenesis is that hrHPV leads to the occurrence of cervical cancer via inhibiting the host's autophagy. The infection of hrHPV will cause the autophagy of cancerous cells, resulting in autophagic cell death, which will suppress the further infection of HPV in return. But the autophagy would be knocked down by the hrHPV, which means the protecting action would end with failure. What's worse, the negative denouement will enhance the infectivity of HPV ultimately, which leads to accelerate cervical carcinogenesis.

Nucleotide Excision Repair Gene ERCC2 and ERCC5 Variants Increase Risk of Uterine Cervical Cancer

Purpose

Defects in the DNA damage repair process can cause genomic instability and play an important role in cervical carcinogenesis. The purpose of this study was to analyze the association of 29 candidate single nucleotide polymorphisms (SNPs) in genes in the DNA repair pathway, TP53, and TP53BP1 with the risk of cervical cancer.

Materials and Methods

Twenty-nine SNPs in four genes in the DNA repair pathway (ERCC2, ERCC5, NBS1, and XRCC1), TP53, and TP53BP1 were genotyped for 478 cervical cancer patients and 922 healthy control subjects, and their effects on cervical carcinogenesis were analyzed.

Results

The most significant association was found for rs17655 in ERCC5, with an age-adjusted p-value < 0.0001, for which a strong additive effect of the risk allele C was observed (odds ratio, 2.01 for CC to GG). On the other hand, another significant polymorphism rs454421 in ERCC2 showed a dominant effect (odds ratio, 1.68 for GA+AA to GG) with an age-adjusted p-value of 0.0009. The association of these polymorphisms remained significant regardless of the age of onset. The significant result for rs17655 was also consistent for subgroups of patients defined by histology and human papillomavirus (HPV) types. However, for rs454421, the association was observed only in patients with squamous cell carcinoma and non-HPV 18 type.

Conclusion

The results of this study show a novel association of cervical cancer and the genes involved in the nucleotide excision pathway in the Korean population.

Changing trends in the incidence (1999-2011) and mortality (1983-2013) of cervical cancer in the Republic of Korea

Cervical cancer is a well-known preventable cancer worldwide. Many countries including Korea have pursued the positive endpoint of a reduction in mortality from cervical cancer. Our aim is to examine changing trends in cervical cancer incidence and mortality after the implementation of a national preventive effort in Korea. Cervical cancer incidence data from 1999 to 2011 and mortality data from 1983 to 2013 were collected from the Korean Statistical Information Service. Yearly age-standardized rates (ASR) per 100,000 were compared using two standards: the 2005 Korean population and the world standard population, based on Segi’s world standard for incidence and the World Health Organization for mortality. In Korea, the age-standardized incidence of cervical cancer per 100,000 persons declined from 17.2 in 2000 to 11.8 in 2011. However, the group aged 25 to 29 showed a higher rate in 2011 (ASR, 6.5) than in 2000 (ASR, 3.6). The age-standardized mortality rate per 100,000 persons dropped from 2.81 in 2000 to 1.95 in 2013. In the worldwide comparison, the incidence rates remained close to the average incidence estimate of more developed regions (ASR, 9.9). The decreasing mortality trend in Korea approached the lower rate observed in Australia (ASR, 1.4) in 2010. Although the incidence rate of cervical cancer is continuously declining in Korea, it is still high relative to other countries. Moreover, incidence and mortality rates in females aged 30 years or under have recently increased. It is necessary to develop effective policy to reduce both incidence and mortality, particularly in younger age groups.

Blood cadmium levels are associated with a decline in lung function in males

BACKGROUND

Cadmium exposure was found to cause a decline in lung function among the general population, but these findings were limited to smokers and gender differences were not explored.

OBJECTIVES

To examine the relationship between cadmium and chronic obstructive pulmonary disease (COPD) according to gender and smoking status in Korea.

METHODS

Cross-sectional data from the Korean National Health and Nutrition Examination Survey from 2008 to 2011 were analyzed. COPD was defined by a pre-bronchodilator forced expiratory volume in 1s divided by forced vital capacity of <0.70. A logistic regression model was used to elucidate the association between blood cadmium levels and COPD according to gender and smoking status.

RESULTS

Among 3861 eligible participants, 3622 were included in the analysis. The prevalence of COPD demonstrated an increasing trend in males (P for trend<0.001), but not in females (P for trend=0.67). After adjusting for covariates, a higher blood cadmium level, but within the normal range, was associated with COPD in males, including those who had never-smoked (P for trend <0.001 and P for trend=0.008). However, a higher blood cadmium level was not significantly associated with COPD in females, including those who had never smoked (P for trend=0.39 and P for trend=0.43).

CONCLUSIONS

A higher blood cadmium level, within the normal range, was associated with COPD in males, including those who had never smoked. However, there was no significant association between blood cadmium levels and COPD in females.

Increased prevalence of chronic lymphocytic thyroiditis in Korean patients with papillary thyroid cancer

Background

In recent years, some reports have suggested that papillary thyroid cancers are more frequently associated with lymphocytic thyroiditis or Hashimoto's thyroiditis. This study investigated a potential increase in the prevalence of chronic lymphocytic thyroiditis among papillary thyroid cancer patients.

Materials and Methods

We used national epidemiological survey data on thyroid cancer patients diagnosed in 1999, 2005, and 2008. A retrospective medical record survey was conducted by representative sampling of a national cancer incidence database. The analysis included 5,378 papillary thyroid cancer patients aged 20–79 years. We calculated the age-standardized prevalence and age-adjusted prevalence ratios using a binomial regression model with a log link for the prevalence of chronic lymphocytic thyroiditis among papillary thyroid cancer patients by sex for each year.

Results

The prevalence of chronic lymphocytic thyroiditis among papillary thyroid cancer patients was 4.0% and 12.8% for men and women in 1999, 6.5% and 24.6% in 2005, and 10.7% and 27.6% in 2008, respectively. Between 1999 and 2008, the age-standardized prevalence of chronic lymphocytic thyroiditis increased 4.1-fold in male patients and 2.0-fold in female patients with papillary thyroid cancer. The prevalence of other thyroid diseases, however, did not increase in either gender.

Conclusions

Among Korean papillary thyroid cancer patients, the prevalence of chronic lymphocytic thyroiditis increased between 1999 and 2008, whereas the prevalence of other thyroid disorders did not change.

Cancer incidence and survival among adolescents and young adults in Korea

Background

In Korea, cancer is the third leading cause of death among adolescents and young adults (AYAs). However, cancer incidence and survival trends among AYAs (15–29 years) have never been studied in Korea. Therefore, this study aimed to investigate the incidence and relative survival rates and their trends among AYAs in Korea.

Materials and Methods

Cancer incidence data from 1999–2010 were obtained from the Korea Central Cancer Registry (KCCR). Each cancer was classified into subgroups according to the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) AYA site recode. Percent distributions, age-specific incidence rates, age-standardized incidence rates per million, and annual percent changes (APCs) were calculated for AYAs according to sex. Five-year relative survival rates were estimated for cases diagnosed between 1993 and 2010 and followed up to 2011.

Results

The age-standardized incidence rates of all cancers combined were 196.4 and 367.8 per million for males and females, respectively (male-to-female (M/F) ratio: 0.5). The age-standardized incidence rates increased from 208.7 per million in 1999 to 396.4 per million in 2010, and the APC was 6.3% (P<0.001). The five most common cancers among AYAs were thyroid carcinoma, non-Hodgkin lymphoma, stomach carcinoma, breast carcinoma, and acute myeloid leukemia. In males, the 5-year relative survival rate improved, from 46.5% in 1993–1995 to 75.9% in 2006–2010. In females, the 5-year relative survival rate also improved, from 66.7% in 1993–1995 to 89.1% in 2006–2010.

Conclusions

Our study showed increases in cancer incidence and improvements in the 5-year relative survival rate among Korean AYAs. This study also provides additional data regarding temporal and geographic trends in cancer that may enhance future efforts to identify factors affecting cancer incidence and responses to treatment among AYAs.