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Tamang P, Gupta M, Thatal A. Digital colposcopy image analysis techniques requirements and their role in clinical diagnosis: a systematic review. Expert Rev Med Devices 2024:1-15. [PMID: 39370601 DOI: 10.1080/17434440.2024.2407549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 09/18/2024] [Indexed: 10/08/2024]
Abstract
INTRODUCTION Colposcopy is a medical procedure for detecting cervical lesions. Access to devices required for colposcopy procedures is limited in low- and middle-income countries. However, various existing digital imaging techniques based on artificial intelligence offer solutions to analyze colposcopy images and address accessibility challenges. METHODS We systematically searched PubMed, National Library of Medicine, and Crossref, which met our inclusion criteria for our study. Various methods and research gaps are addressed, including how variability in images and sample size affect the accuracy of the methods. The quality and risk of each study were assessed following the QUADAS-2 guidelines. RESULTS Development of image analysis and compression algorithms, and their efficiency are analyzed. Most of the studied algorithms have attained specificity, sensitivity, and accuracy which range from 86% to 95%, 75%-100%, and 100%, respectively, and these results were validated by the clinician to analyze the images quickly and thus minimize biases among the clinicians. CONCLUSION This systematic review provides a comprehensive study on colposcopy image analysis stages and the advantages of utilizing digital imaging techniques to enhance image analysis and diagnostic procedures and ensure prompt consultations. Furthermore, compression techniques can be applied to send medical images over media for further analysis among periphery hospitals.
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Affiliation(s)
- Parimala Tamang
- Department of Computer Applications, Sikkim Manipal Institute of Technology, Sikkim Manipal University, Sikkim, India
| | - Mousumi Gupta
- Department of Computer Applications, Sikkim Manipal Institute of Technology, Sikkim Manipal University, Sikkim, India
| | - Annet Thatal
- Department of Obstetrics and Gynecology, Al-Falah University, Faridabad, India
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Wang R, Ekem L, Gallagher J, Factor RE, Hall A, Ramanujam N. A color-based tumor segmentation method for clinical ex vivo breast tissue assessment utilizing a multi-contrast brightfield imaging strategy. JOURNAL OF BIOPHOTONICS 2024; 17:e202300241. [PMID: 38348582 PMCID: PMC11065618 DOI: 10.1002/jbio.202300241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/20/2024] [Accepted: 01/21/2024] [Indexed: 03/21/2024]
Abstract
We demonstrate an automated two-step tumor segmentation method leveraging color information from brightfield images of fresh core needle biopsies of breast tissue. Three different color spaces (HSV, CIELAB, YCbCr) were explored for the segmentation task. By leveraging white-light and green-light images, we identified two different types of color transformations that could separate adipose from benign and tumor or cancerous tissue. We leveraged these two distinct color transformation methods in a two-step process where adipose tissue segmentation was followed by benign tissue segmentation thereby isolating the malignant region of the biopsy. Our tumor segmentation algorithm and imaging probe could highlight suspicious regions on unprocessed biopsy tissue to guide selection of areas most similar to malignant tissues for tissue pathology whether it be formalin fixed or frozen sections, expedite tissue selection for molecular testing, detect positive tumor margins, or serve an alternative to tissue pathology, in countries where these services are lacking.
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Affiliation(s)
- Roujia Wang
- Department of Biomedical Engineering, Duke University, 27710 Durham, NC, USA
| | - Lillian Ekem
- Department of Biomedical Engineering, Duke University, 27710 Durham, NC, USA
| | - Jennifer Gallagher
- Department of Surgery, Duke University School of Medicine, 27710 Durham, NC, USA
| | | | - Allison Hall
- Department of Pathology, Duke University, 27710 Durham, NC, USA
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, 27710 Durham, NC, USA
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, 27710 Durham, NC, USA
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Feasibility and Outcome of Training Field Workers to Use the Transvaginal Colposcope for Point of Care Diagnosis and Management of Precancerous Cervical Lesions. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2023. [DOI: 10.1007/s40944-022-00681-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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4
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Qin D, Bai A, Xue P, Seery S, Wang J, Mendez MJG, Li Q, Jiang Y, Qiao Y. Colposcopic accuracy in diagnosing squamous intraepithelial lesions: a systematic review and meta-analysis of the International Federation of Cervical Pathology and Colposcopy 2011 terminology. BMC Cancer 2023; 23:187. [PMID: 36823557 PMCID: PMC9951444 DOI: 10.1186/s12885-023-10648-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Colposcopy is an important tool in diagnosing cervical cancer, and the International Federation of Cervical Pathology and Colposcopy (IFCPC) issued the latest version of the guidelines in 2011. This study aims to systematically assess the accuracy of colposcopy in predicting low-grade squamous intraepithelial lesions or worse (LSIL+) / high-grade squamous intraepithelial lesions or worse (HSIL+) under the 2011 IFCPC terminology. METHODS We performed a systematic review and meta-analysis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for studies about the performance of colposcopy in diagnosing cervical intraepithelial neoplasia under the new IFCPC colposcopy terminology from PubMed, Embase, Web of Science and the Cochrane database. Data were independently extracted by two authors and an overall diagnostic performance index was calculated under two colposcopic thresholds. RESULTS Totally, fifteen articles with 22,764 participants in compliance with the criteria were included in meta-analysis. When colposcopy was used to detect LSIL+, the combined sensitivity and specificity were 0.92 (95% CI 0.88-0.95) and 0.51 (0.43-0.59), respectively. When colposcopy was used to detect HSIL+, the combined sensitivity and specificity were 0.68 (0.58-0.76) and 0.93 (0.88-0.96), respectively. CONCLUSION In accordance with the 2011 IFCPC terminology, the accuracy of colposcopy has improved in terms of both sensitivity and specificity. Colposcopy is now more sensitive with LSIL+ taken as the cut-off value and is more specific to HSIL+. These findings suggest we are avoiding under- or overdiagnosis both of which impact on patients' well-being.
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Affiliation(s)
- Dongxu Qin
- grid.506261.60000 0001 0706 7839School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730 China
| | - Anying Bai
- grid.506261.60000 0001 0706 7839School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730 China
| | - Peng Xue
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Samuel Seery
- grid.9835.70000 0000 8190 6402Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4YW UK
| | - Jiaxu Wang
- grid.506261.60000 0001 0706 7839School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730 China
| | - Maria Jose Gonzalez Mendez
- grid.411971.b0000 0000 9558 1426School of Public Health, Dalian Medical University, Dalian, 116044 Liaoning China
| | - Qing Li
- grid.469593.40000 0004 1777 204XDiagnosis and Treatment for Cervical Lesions Center, Shenzhen Maternity and Child Healthcare Hospital, Shenzhen, 518028 China
| | - Yu Jiang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Youlin Qiao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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5
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Wang R, Deutsch RJ, Sunassee ED, Crouch BT, Ramanujam N. Adaptive Design of Fluorescence Imaging Systems for Custom Resolution, Fields of View, and Geometries. BME FRONTIERS 2023; 4:0005. [PMID: 37849673 PMCID: PMC10521686 DOI: 10.34133/bmef.0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/27/2022] [Indexed: 10/19/2023] Open
Abstract
Objective and Impact Statement: We developed a generalized computational approach to design uniform, high-intensity excitation light for low-cost, quantitative fluorescence imaging of in vitro, ex vivo, and in vivo samples with a single device. Introduction: Fluorescence imaging is a ubiquitous tool for biomedical applications. Researchers extensively modify existing systems for tissue imaging, increasing the time and effort needed for translational research and thick tissue imaging. These modifications are application-specific, requiring new designs to scale across sample types. Methods: We implemented a computational model to simulate light propagation from multiple sources. Using a global optimization algorithm and a custom cost function, we determined the spatial positioning of optical fibers to generate 2 illumination profiles. These results were implemented to image core needle biopsies, preclinical mammary tumors, or tumor-derived organoids. Samples were stained with molecular probes and imaged with uniform and nonuniform illumination. Results: Simulation results were faithfully translated to benchtop systems. We demonstrated that uniform illumination increased the reliability of intraimage analysis compared to nonuniform illumination and was concordant with traditional histological findings. The computational approach was used to optimize the illumination geometry for the purposes of imaging 3 different fluorophores through a mammary window chamber model. Illumination specifically designed for intravital tumor imaging generated higher image contrast compared to the case in which illumination originally optimized for biopsy images was used. Conclusion: We demonstrate the significance of using a computationally designed illumination for in vitro, ex vivo, and in vivo fluorescence imaging. Application-specific illumination increased the reliability of intraimage analysis and enhanced the local contrast of biological features. This approach is generalizable across light sources, biological applications, and detectors.
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Affiliation(s)
- Roujia Wang
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Riley J. Deutsch
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | - Brian T. Crouch
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Nirmala Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
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Jiang T, Kost S, Doshi P, Ho PC, Phillips SD, Mutindi E, Mueller JL, Fitzgerald TN. Crucial Business Model Elements for Medical Device Startup Companies in Emerging Markets. Value Health Reg Issues 2023; 33:83-90. [PMID: 36327768 DOI: 10.1016/j.vhri.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Medical devices that suit the needs and challenges of low- and middle-income countries are desperately needed. To provide sustainable access to such devices, business approaches must be developed to meet the demands of individual economic, healthcare, and innovation ecosystems. Currently, there is a gap in the literature regarding business models for medical devices in low- and middle-income countries. METHODS A multimodal approach using literature review and key informant interviews was performed to determine critical components of business models for medical device organizations operating in LMICs, specifically focusing on models in emerging markets. RESULTS The search resulted in 4,674 articles, of which 31 were determined to be relevant and were reviewed. Additional sources included 1 government website, 5 nongovernmental organization websites, 2 private enterprises, and 6 publicly available, non-peer reviewed websites and 1 video. From these sources, four major criteria were found to be necessary for successful development of medical device business models in emerging markets: value proposition, partnerships, strategic pricing, and funding models. CONCLUSIONS Innovators must custom tailor their business model when implementing these elements to the regulatory, cultural, and economic landscapes of each setting. This will improve access to safer, affordable medical care and successfully bring innovative technologies to emerging markets.
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Affiliation(s)
- Tiffany Jiang
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Samantha Kost
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Pratik Doshi
- School of Medicine, Duke University, Durham, NC, USA; Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Pei Ching Ho
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | | | | | - Jenna L Mueller
- Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Tamara N Fitzgerald
- School of Medicine, Duke University, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA.
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Natarajan J, Mathur S, Vishnubhatla S, Kumar S, Vashist S, Ramanujam N, Singhal S, Meena J, Tanwar P, Bhatla N. Can portable Colposcopes Replace Standard-of-care Colposcopes? A Crossover Trial of Two Portable Colposcopes with a Standard-of-Care Video Colposcope. Asian Pac J Cancer Prev 2022; 23:4013-4021. [PMID: 36579981 PMCID: PMC9971471 DOI: 10.31557/apjcp.2022.23.12.4013] [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: 08/25/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Screen positive women need to be triaged by colposcopy which is a major challenge in low-middle income countries. Portable colposcopes may overcome many challenges, reduce referrals and enable a single visit approach. This study assessed the performance of portable colposcopes and potential to reduce referral. METHOD This crossover randomised study enrolled women aged 25 to 65 years with abnormal screening result or cervical symptoms. All women underwent visual inspection with acetic acid (VIA), HPV test, colposcopy with two portable colposcopes (Gynocular®, Gynius, Sweden, and Pocket® transvaginal colposcope, Duke University, NC, USA) and a standard video colposcope, and biopsy. Colposcopic Swede score agreement between portable and video colposcopes, as well as agreement of Swede score with histology were calculated for each device. The potential impact of portable colposcopes in a single visit approach was assessed based on the final diagnosis. RESULTS Among 250 subjects, 27(10.80%) had high-grade cervical intraepithelial neoplasia (CIN2+) lesions. Swede scores for Pocket and Gynocular colposcopes were similar to video colposcope in 248 (99.20%) and 247 (98.80%) subjects, respectively (agreement scores 0.9969 and 0.9954, respectively). At a Swede score cut-off of ≥5, all three devices had identical sensitivity, specificity, positive and negative predictive value of 96.30%, 92.30%, 60.50% and 99.50,. Ablative treatment offered at field setting would result in optimal treatment in 52.0% and 85.1% cases when screened with VIA and HPV test respectively; using Pocket colposcope could improve this to 94.0% and 95.9%, respectively. Overtreatment and referral rates reduced from 46.8% and 12.4% to 4.8% and 6.0%, respectively, when VIA test is followed by triage with pocket colposcope. These outcomes were comparable to screening with HPV followed by colposcopy triage. CONCLUSIONS Pocket colposcope performed comparably to the video colposcope. Used by healthcare providers in the field setting, they can augment the results of VIA significantly.
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Affiliation(s)
- Jayashree Natarajan
- Department of Gynaecological Oncology, Cancer Institute (WIA), Adyar, Chennai, India.
| | - Sandeep Mathur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Sunesh Kumar
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Shachi Vashist
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, NC, USA.
| | - Seema Singhal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Jyoti Meena
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India.
| | - Pranay Tanwar
- Laboratory Oncology, Dr B.R.A.,IRCH, All India Institute of Medical Sciences, New Delhi, India.
| | - Neerja Bhatla
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India. ,For Correspondence:
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Beyer K, Kasasa S, Anguzu R, Lukande R, Nambooze S, Amulen PM, Zhou Y, Nansereko B, Jankowski C, Oyana T, Savino D, Feustel K, Wabinga H. High-resolution disease maps for cancer control in low-resource settings: A spatial analysis of cervical cancer incidence in Kampala, Uganda. J Glob Health 2022; 12:04032. [PMID: 35493778 PMCID: PMC9022722 DOI: 10.7189/jogh.12.04032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The global burden of cervical cancer is concentrated in low-and middle-income countries (LMICs), with the greatest burden in Africa. Targeting limited resources to populations with the greatest need to maximize impact is essential. The objectives of this study were to geocode cervical cancer data from a population-based cancer registry in Kampala, Uganda, to create high-resolution disease maps for cervical cancer prevention and control planning, and to share lessons learned to optimize efforts in other low-resource settings. Methods Kampala Cancer Registry records for cervical cancer diagnoses between 2008 and 2015 were updated to include geographies of residence at diagnosis. Population data by age and sex for 2014 was obtained from the Uganda Bureau of Statistics. Indirectly age-standardized incidence ratios were calculated for sub-counties and estimated continuously across the study area using parish level data. Results Overall, among 1873 records, 89.6% included a valid sub-county and 89.2% included a valid parish name. Maps revealed specific areas of high cervical cancer incidence in the region, with significant variation within sub-counties, highlighting the importance of high-resolution spatial detail. Conclusions Population-based cancer registry data and geospatial mapping can be used in low-resource settings to support cancer prevention and control efforts, and to create the potential for research examining geographic factors that influence cancer outcomes. It is essential to support LMIC cancer registries to maximize the benefits from the use of limited cancer control resources.
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Affiliation(s)
- Kirsten Beyer
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Ronald Anguzu
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert Lukande
- Makerere University, Kampala, Uganda
- Kampala Cancer Registry, Kampala, Uganda
| | - Sarah Nambooze
- Makerere University, Kampala, Uganda
- Kampala Cancer Registry, Kampala, Uganda
| | - Phoebe M Amulen
- Makerere University, Kampala, Uganda
- Kampala Cancer Registry, Kampala, Uganda
| | - Yuhong Zhou
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | | | | | | | - Henry Wabinga
- Makerere University, Kampala, Uganda
- Kampala Cancer Registry, Kampala, Uganda
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Allanson ER, Phoolcharoen N, Salcedo MP, Fellman B, Schmeler KM. Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis. JCO Glob Oncol 2021; 7:1711-1721. [PMID: 34936374 PMCID: PMC8710337 DOI: 10.1200/go.21.00168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/10/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening. METHODS This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024. RESULTS Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I2 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I2 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I2 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I2 61.3%). CONCLUSION Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.
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Affiliation(s)
- Emma R. Allanson
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Natacha Phoolcharoen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital of Porto Alegre, Porto Alegre, Brazil
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mila P. Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital of Porto Alegre, Porto Alegre, Brazil
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M. Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
Cervical cancer is one of the commonest cancers afflicting women in low and middle income countries, however, both primary prevention with human papillomavirus vaccination, and secondary prevention with screening programs and treatment of preinvasive disease are possible. A coordinated approach to eliminating cervical cancer, as has been called for by the World Health Organization, requires a complex series of steps at all levels of a health system. This article outlines the current state of cervical cancer prevention in low and middle income countries, the innovations being employed to improve outcomes, and consideration of the next steps needed as we move towards global elimination.
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Affiliation(s)
- Emma R Allanson
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, Texas
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11
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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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12
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Rahatgaonkar V, Uchale P, Oka G. Comparative Study of Smart Scope® Visual Screening Test with Naked Eye Visual Screening and Pap Test. Asian Pac J Cancer Prev 2020; 21:3509-3515. [PMID: 33369446 PMCID: PMC8046303 DOI: 10.31557/apjcp.2020.21.12.3509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Cervical cancer is a major contributor to mortality and morbidity in women. Naked eye visual screening (NE test) and Pap test are commonly used for cervical cancer screening. Both tests have inherent limitations like low sensitivity (Pap test) and subjectivity in interpretation, lack of permanent record and overestimation (NE test). Here, Smart Scope® visual screening test (SS test) was compared with NE and Pap tests. Smart Scope® is a small, hand-held device that captures cervical images attached to a tablet to store data. Objective: To compare SS test with Pap and NE tests. Study Design: This prospective observational study was conducted at a tertiary care hospital in India, over 16 months. A total of 509 women in the age group of 25 to 65 years were included in the study as per the inclusion criteria. All the participants underwent Pap test, NE test and SS test. Screen positives on any one test were advised colposcopy and biopsy. Results: Out of 154 screen-positive women, 49 visited for follow-up colposcopy-guided biopsy. Nine incidental biopsies of screen-negative women were included in the data. Thus, statistical analysis was carried out based on 58 available histopathology results. Out of 58 biopsies, 8 were normal, 30 were benign lesions, 18 were precancerous and 2 were cancerous lesions. SS test was found to have a sensitivity and NPV of 100% each, PPV of 45.4% and a specificity of 36.8%. Sensitivity and specificity of NE test was 90% and 39.5% respectively, PPV was 43.9% and NPV was 88.2%. Pap smear had a sensitivity of 25% and specificity of 84.2%, PPV of 45.5% and NPV of 68.08%. Conclusion: SS test has great potential to be a primary screening test in low-resource settings due to its better sensitivity and NPV as compared to NE and Pap tests.
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Affiliation(s)
- Veena Rahatgaonkar
- Department of Gynecology, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | - Pooja Uchale
- Department of Research, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
| | - Gauri Oka
- Department of Research, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
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Taghavi K, Rohner E, Basu P, Low N, Rutjes A, Bohlius J. Screening test accuracy of portable devices that can be used to perform colposcopy for detecting CIN2+ in low- and middle-income countries: a systematic review and meta-analysis. BMC Womens Health 2020; 20:253. [PMID: 33198721 PMCID: PMC7670616 DOI: 10.1186/s12905-020-01121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/05/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Portable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited. The objective of this study was to systematically review the diagnostic test accuracy (DTA) of these devices for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+). METHODS In accordance with our protocol (Prospero CRD42018104286), we searched Embase, Medline and the Cochrane Controlled Register of Trials up to 9/2019. We included DTA studies, which investigated portable devices with moderate-to-high optical magnification (≥ 6×) for colposcopy, as described in the manual for Colposcopy and Treatment by the International Agency for Research on Cancer, with a histopathological reference standard. We used the QUADAS-2 tool to assess study quality. We examined results for sensitivity and specificity in paired forest plots, stratified by stages in the clinical pathway. We pooled estimates of test accuracy for the index test, used as an add-on to other tests, using a bivariate random-effect model. RESULTS We screened 1737 references and assessed 239 full-text articles for eligibility. Five single-gate DTA studies, including 2693 women, met the inclusion criteria. Studies evaluated two devices (Gynocular™ and Pocket) at different stages of the screening pathway. In three studies, which used the index test in an add-on capacity in 1273 women, we found a pooled sensitivity of 0.79 (95% CI 0.55-0.92) and specificity of 0.83 (95% CI 0.59-0.94). The main sources of bias were partial verification, incorporation and classification bias. CONCLUSION Few studies have evaluated portable devices able to perform colposcopy, so their accuracy for the detection of CIN2+ remains uncertain. Future studies should include patient-relevant and long-term outcomes, including missed cases, overtreatment, residual and recurrent disease. To meet the challenge of eliminating cervical cancer in LMIC, methods for visual assessment of the cervix need urgent redress.
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Affiliation(s)
- Katayoun Taghavi
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
- The Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland.
| | - Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Anne Rutjes
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
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14
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Asiedu MN, Skerrett E, Sapiro G, Ramanujam N. Combining multiple contrasts for improving machine learning-based classification of cervical cancers with a low-cost point-of-care Pocket colposcope. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:1148-1151. [PMID: 33018190 DOI: 10.1109/embc44109.2020.9175858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We apply feature-extraction and machine learning methods to multiple sources of contrast (acetic acid, Lugol's iodine and green light) from the white Pocket Colposcope, a low-cost point of care colposcope for cervical cancer screening. We combine features from the sources of contrast and analyze diagnostic improvements with addition of each contrast. We find that overall AUC increases with additional contrast agents compared to using only one source.
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15
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Asiedu MN, Agudogo JS, Dotson ME, Skerrett E, Krieger MS, Lam CT, Agyei D, Amewu J, Asah-Opoku K, Huchko M, Schmitt JW, Samba A, Srofenyoh E, Ramanujam N. A novel speculum-free imaging strategy for visualization of the internal female lower reproductive system. Sci Rep 2020; 10:16570. [PMID: 33024146 PMCID: PMC7538883 DOI: 10.1038/s41598-020-72219-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 12/16/2022] Open
Abstract
Fear of the speculum and feelings of vulnerability during the gynecologic exams are two of the biggest barriers to cervical cancer screening for women. To address these barriers, we have developed a novel, low-cost tool called the Callascope to reimagine the gynecological exam, enabling clinician and self-imaging of the cervix without the need for a speculum. The Callascope contains a 2 megapixel camera and contrast agent spray mechanism housed within a form factor designed to eliminate the need for a speculum during contrast agent administration and image capture. Preliminary bench testing for comparison of the Callascope camera to a $20,000 high-end colposcope demonstrated that the Callascope camera meets visual requirements for cervical imaging. Bench testing of the spray mechanism demonstrates that the contrast agent delivery enables satisfactory administration and cervix coverage. Clinical studies performed at Duke University Medical Center, Durham, USA and in Greater Accra Regional Hospital, Accra, Ghana assessed (1) the Callascope's ability to visualize the cervix compared to the standard-of-care speculum exam, (2) the feasibility and willingness of women to use the Callascope for self-exams, and (3) the feasibility and willingness of clinicians and their patients to use the Callascope for clinician-based examinations. Cervix visualization was comparable between the Callascope and speculum (83% or 44/53 women vs. 100%) when performed by a clinician. Visualization was achieved in 95% (21/22) of women who used the Callascope for self-imaging. Post-exam surveys indicated that participants preferred the Callascope to a speculum-based exam. Our results indicate the Callascope is a viable option for clinician-based and self-exam speculum-free cervical imaging.Clinical study registration ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/record/ NCT00900575, Pan African Clinical Trial Registry (PACTR) https://www.pactr.org/ PACTR201905806116817.
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Affiliation(s)
- Mercy N. Asiedu
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Júlia S. Agudogo
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Mary E. Dotson
- grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Erica Skerrett
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Marlee S. Krieger
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA
| | - Christopher T. Lam
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
| | - Doris Agyei
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Juliet Amewu
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Kwaku Asah-Opoku
- grid.415489.50000 0004 0546 3805Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana ,grid.8652.90000 0004 1937 1485The University of Ghana Medical School, Accra, Ghana
| | - Megan Huchko
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Obstetrics and Gynecology, Duke Medical Center, Durham, NC USA
| | - John W. Schmitt
- grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA ,grid.414179.e0000 0001 2232 0951Department of Obstetrics and Gynecology, Duke Medical Center, Durham, NC USA
| | - Ali Samba
- grid.415489.50000 0004 0546 3805Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana ,grid.8652.90000 0004 1937 1485The University of Ghana Medical School, Accra, Ghana
| | - Emmanuel Srofenyoh
- Family Planning and Reproductive Health Unit, Greater Accra Regional Hospital, Accra, Ghana
| | - Nirmala Ramanujam
- grid.26009.3d0000 0004 1936 7961Department of Biomedical Engineering, Duke University, Gross Hall Rm 370, Durham, NC 27713 USA ,grid.26009.3d0000 0004 1936 7961Center for Global Women’s Health Technologies, Duke University, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Duke Global Health Institute, Duke University, Durham, NC USA
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16
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Bae JK, Roh HJ, You JS, Kim K, Ahn Y, Askaruly S, Park K, Yang H, Jang GJ, Moon KH, Jung W. Quantitative Screening of Cervical Cancers for Low-Resource Settings: Pilot Study of Smartphone-Based Endoscopic Visual Inspection After Acetic Acid Using Machine Learning Techniques. JMIR Mhealth Uhealth 2020; 8:e16467. [PMID: 32159521 PMCID: PMC7097827 DOI: 10.2196/16467] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Approximately 90% of global cervical cancer (CC) is mostly found in low- and middle-income countries. In most cases, CC can be detected early through routine screening programs, including a cytology-based test. However, it is logistically difficult to offer this program in low-resource settings due to limited resources and infrastructure, and few trained experts. A visual inspection following the application of acetic acid (VIA) has been widely promoted and is routinely recommended as a viable form of CC screening in resource-constrained countries. Digital images of the cervix have been acquired during VIA procedure with better quality assurance and visualization, leading to higher diagnostic accuracy and reduction of the variability of detection rate. However, a colposcope is bulky, expensive, electricity-dependent, and needs routine maintenance, and to confirm the grade of abnormality through its images, a specialist must be present. Recently, smartphone-based imaging systems have made a significant impact on the practice of medicine by offering a cost-effective, rapid, and noninvasive method of evaluation. Furthermore, computer-aided analyses, including image processing-based methods and machine learning techniques, have also shown great potential for a high impact on medicinal evaluations. OBJECTIVE In this study, we demonstrate a new quantitative CC screening technique and implement a machine learning algorithm for smartphone-based endoscopic VIA. We also evaluated the diagnostic performance and practicability of the approach based on the results compared to the gold standard and from physicians' interpretation. METHODS A smartphone-based endoscope system was developed and applied to the VIA screening. A total of 20 patients were recruited for this study to evaluate the system. Overall, five were healthy, and 15 were patients who had shown a low to high grade of cervical intraepithelial neoplasia (CIN) from both colposcopy and cytology tests. Endoscopic VIA images were obtained before a loop electrosurgical excision procedure for patients with abnormal tissues, and their histology tissues were collected. Endoscopic VIA images were assessed by four expert physicians relative to the gold standard of histopathology. Also, VIA features were extracted from multiple steps of image processing techniques to find the differences between abnormal (CIN2+) and normal (≤CIN1). By using the extracted features, the performance of different machine learning classifiers, such as k-nearest neighbors (KNN), support vector machine, and decision tree (DT), were compared to find the best algorithm for VIA. After determining the best performing classifying model, it was used to evaluate the screening performance of VIA. RESULTS An average accuracy of 78%, with a Cohen kappa of 0.571, was observed for the evaluation of the system by four physicians. Through image processing, 240 sliced images were obtained from the cervicogram at each clock position, and five features of VIA were extracted. Among the three models, KNN showed the best performance for finding VIA within holdout 10-fold cross-validation, with an accuracy of 78.3%, area under the curve of 0.807, a specificity of 80.3%, and a sensitivity of 75.0%, respectively. The trained model performed using an unprovided data set resulted in an accuracy of 80.8%, specificity of 84.1%, and sensitivity of 71.9%. Predictions were visualized with intuitive color labels, indicating the normal/abnormal tissue using a circular clock-type segmentation. Calculating the overlapped abnormal tissues between the gold standard and predicted value, the KNN model overperformed the average assessments of physicians for finding VIA. CONCLUSIONS We explored the potential of the smartphone-based endoscopic VIA as an evaluation technique and used the cervicogram to evaluate normal/abnormal tissue using machine learning techniques. The results of this study demonstrate its potential as a screening tool in low-resource settings.
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Affiliation(s)
- Jung Kweon Bae
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Hyun-Jin Roh
- Department of Obstetrics and Gynaecology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Joon S You
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Kyungbin Kim
- Department of Pathology, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Yujin Ahn
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Sanzhar Askaruly
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Kibeom Park
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Hyunmo Yang
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
| | - Gil-Jin Jang
- School of Electronics Engineering, Kyungpook National University, Daegu, Republic of Korea
| | - Kyung Hyun Moon
- Department of Urology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Woonggyu Jung
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, Republic of Korea
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17
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Kundrod KA, Smith CA, Hunt B, Schwarz RA, Schmeler K, Richards-Kortum R. Advances in technologies for cervical cancer detection in low-resource settings. Expert Rev Mol Diagn 2019; 19:695-714. [PMID: 31368827 DOI: 10.1080/14737159.2019.1648213] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Cervical cancer mortality rates remain high in low- and middle-income countries (LMICs) and other medically underserved areas due to challenges with implementation and sustainability of routine screening, accurate diagnosis, and early treatment of preinvasive lesions. Areas covered: In this review, we first discuss the standard of care for cervical cancer screening and diagnosis in high- and low-resource settings, biomarkers that correlate to cervical precancer and cancer, and needs for new tests. We review technologies for screening and diagnosis with a focus on tests that are already in use in LMICs or have the potential to be adapted for use in LMICs. Finally, we provide perspectives on the next five years of technology development for improved cervical cancer screening and diagnosis in LMICs. Expert opinion: Innovation toward improved molecular and imaging tests is needed to enable effective, affordable see-and-treat approaches to detect and treat cervical precancer in a single visit. Current molecular tests remain too complex and/or costly for widespread use. Especially with imaging tests, decision support may improve performance of new technologies.
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Affiliation(s)
| | - Chelsey A Smith
- Department of Bioengineering, Rice University , Houston , TX , USA
| | - Brady Hunt
- Department of Bioengineering, Rice University , Houston , TX , USA
| | | | - Kathleen Schmeler
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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18
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Crouch BT, Gallagher J, Wang R, Duer J, Hall A, Soo MS, Hughes P, Haystead T, Ramanujam N. Exploiting heat shock protein expression to develop a non-invasive diagnostic tool for breast cancer. Sci Rep 2019; 9:3461. [PMID: 30837677 PMCID: PMC6400939 DOI: 10.1038/s41598-019-40252-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/12/2019] [Indexed: 01/23/2023] Open
Abstract
Leveraging the unique surface expression of heat shock protein 90 (Hsp90) in breast cancer provides an exciting opportunity to develop rapid diagnostic tests at the point-of-care setting. Hsp90 has previously been shown to have elevated expression levels across all breast cancer receptor subtypes. We have developed a non-destructive strategy using HS-27, a fluorescently-tethered Hsp90 inhibitor, to assay surface Hsp90 expression on intact tissue specimens and validated our approach in clinical samples from breast cancer patients across estrogen receptor positive, Her2-overexpressing, and triple negative receptor subtypes. Utilizing a pre-clinical biopsy model, we optimized three imaging parameters that may affect the specificity of HS-27 based diagnostics – time between tissue excision and staining, agent incubation time, and agent dose, and translated our strategy to clinical breast cancer samples. Findings indicated that HS-27 florescence was highest in tumor tissue, followed by benign tissue, and finally followed by mammoplasty negative control samples. Interestingly, fluorescence in tumor samples was highest in Her2+ and triple negative subtypes, and inversely correlated with the presence of tumor infiltrating lymphocytes indicating that HS-27 fluorescence increases in aggressive breast cancer phenotypes. Development of a Gaussian support vector machine classifier based on HS-27 fluorescence features resulted in a sensitivity and specificity of 82% and 100% respectively when classifying tumor and benign conditions, setting the stage for rapid and automated tissue diagnosis at the point-of-care.
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Affiliation(s)
- Brian T Crouch
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
| | | | - Roujia Wang
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Joy Duer
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA
| | - Allison Hall
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Mary Scott Soo
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Philip Hughes
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Timothy Haystead
- Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Nirmala Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.,Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
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19
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Mueller JL, Lam CT, Dahl D, Asiedu MN, Krieger MS, Bellido-Fuentes Y, Kellish M, Peters J, Erkanli A, Ortiz EJ, Muasher LC, Taylor PT, Schmitt JW, Venegas G, Ramanujam N. Portable Pocket colposcopy performs comparably to standard-of-care clinical colposcopy using acetic acid and Lugol's iodine as contrast mediators: an investigational study in Peru. BJOG 2018; 125:1321-1329. [PMID: 29893472 DOI: 10.1111/1471-0528.15326] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Our goal was to develop a tele-colposcopy platform for primary-care clinics to improve screening sensitivity and access. Specifically, we developed a low-cost, portable Pocket colposcope and evaluated its performance in a tertiary healthcare centre in Peru. DESIGN AND SETTING Images of the cervix were captured with a standard-of-care and Pocket colposcope at la Liga Contra el Cáncer in Lima, Peru. POPULATION Two hundred Peruvian women with abnormal cytology and/or human papillomavirus positivity were enrolled. METHODS Images were collected using acetic acid and Lugol's iodine as contrast agents. Biopsies were taken as per standard-of-care procedures. MAIN OUTCOME MEASURES After passing quality review, images from 129 women were sent to four physicians who provided a diagnosis for each image. RESULTS Physician interpretation of images from the two colposcopes agreed 83.1% of the time. The average sensitivity and specificity of physician interpretation compared with pathology was similar for the Pocket (sensitivity = 71.2%, specificity = 57.5%) and standard-of-care (sensitivity = 79.8%, specificity = 56.6%) colposcopes. When compared with a previous study where only acetic acid was applied to the cervix, results indicated that adding Lugol's iodine as a secondary contrast agent improved the percent agreement between colposcopes for all pathological categories by up to 8.9% and the sensitivity and specificity of physician interpretation compared with pathology by over 6.0 and 9.0%, respectively. CONCLUSIONS The Pocket colposcope performance was similar to that of a standard-of-care colposcope when used to identify precancerous and cancerous lesions using acetic acid and Lugol's iodine during colposcopy examinations in Peru. TWEETABLE ABSTRACT The Pocket colposcope performance was similar to that of a standard-of-care colposcope when identifying cervical lesions.
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Affiliation(s)
- J L Mueller
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - C T Lam
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - D Dahl
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - M N Asiedu
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - M S Krieger
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | - M Kellish
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - J Peters
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - A Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Medical School, Durham, NC, USA
| | - E J Ortiz
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - L C Muasher
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - P T Taylor
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.,Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - J W Schmitt
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - G Venegas
- Liga Contra el Cáncer, Pueblo Libre, Lima, Peru
| | - N Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
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Silkensen SL, Schiffman M, Sahasrabuddhe V, Flanigan JS. Is It Time to Move Beyond Visual Inspection With Acetic Acid for Cervical Cancer Screening? GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:242-246. [PMID: 29959268 PMCID: PMC6024629 DOI: 10.9745/ghsp-d-18-00206] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Newly emerging low-cost molecular assays and improved visual tests for cervical cancer screening call into question the role of visual inspection with acetic acid (VIA). VIA-based screening continues to offer a low-cost, single-visit approach for screening. However, VIA is highly rater-dependent and has problematic accuracy. RNA, DNA, and protein tests are now available. They offer greater accuracy and the option for self-sampling, but the testing kits are expensive. As these new options continue to improve, the time to move beyond VIA is fast approaching.
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Affiliation(s)
- Shannon L Silkensen
- Center for Global Health, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Vikrant Sahasrabuddhe
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - John S Flanigan
- Center for Global Health, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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