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Mungo C, Osongo CO, Ambaka J, Omoto J, Cohen CR. Efficacy of thermal ablation for treatment of biopsy-confirmed high-grade cervical precancer among women living with HIV in Kenya. Int J Cancer 2023; 153:1971-1977. [PMID: 37715464 PMCID: PMC11081005 DOI: 10.1002/ijc.34737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 09/17/2023]
Abstract
The World Health Organization recommends thermal ablation (TA) as an alternative to cryotherapy within "screen-and-treat" cervical cancer programs in low- and middle-income countries (LMICs), including among women living with HIV (WLWH). Data on TA efficacy among WLWH are limited, however. We conducted a clinical trial to evaluate efficacy of TA for treatment of biopsy-confirmed cervical intraepithelial neoplasia grades 2 and 3 (CIN2/3) among WLWH in Kenya. Nonpregnant HPV-positive WLWH age 25 to 65 years underwent colposcopy-directed biopsy, and same-day treatment with TA, if eligible. Women with biopsy-confirmed CIN2/3 at baseline had colposcopy-directed biopsies at 12 months to determine cure. A total of 376 participants underwent TA during the study period. At baseline, 238 (63.3%) had normal histology, 39 (10.4%) had CIN1, 15 (4.0%) had CIN2, 55 (14.6%) had CIN3, 7 (1.9%) had microinvasive cancer and 22 (5.6%) had indeterminate results. Twelve-month follow-up pathology results are available for 59 of 70 (84.3%) participants with CIN2/3 at baseline. Of these, 39 (66.1%, 95% CI 0.54-0.99) had successful treatment, defined as biopsy-confirmed CIN1 or normal findings, while 20 (33.9%, 95% CI 0.22-0.46) had treatment failure, defined as persistent biopsy-confirmed CIN2 or worse. Treatment failure was 23.1% (95% CI 0.17-0.46) and 39.9% (95% CI 0.23-0.51) among women with CIN2 and CIN3 at baseline, respectively. HIV-positive women with CIN2/3 have high rates of treatment failure at 1-year following thermal ablation. This highlights a significant limitation in the current WHO cervical cancer secondary-prevention strategy and calls for strategies to optimize cervical precancer treatment in this population.
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Affiliation(s)
- Chemtai Mungo
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Jackton Omoto
- Department of Obstetrics and Gynecology, Maseno University School of Medicine, Kisumu, Kenya
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA
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Balli C, Kenfack B, Horo A, Jeronimo J, Abatsong E, Wisniak A, Vassilakos P, Petignat P. Transformation Zone Assessment Using Visual Inspection With Acetic Acid Before and After Thermal Ablation: Implications for Follow-Up. JCO Glob Oncol 2023; 9:e2200241. [PMID: 36854076 PMCID: PMC10166473 DOI: 10.1200/go.22.00241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
PURPOSE Thermal ablation (TA) has become the conventional method for treatment of precancerous cervical lesions in low-resource settings. After TA, both the squamocolumnar junction (SCJ) and the transformation zone (TZ) may be subject to change. Our aim was to evaluate SCJ and TZ variability after TA. METHODS Study data were collected in a large prospective trial of a cervical cancer screening campaign in Cameroon. For each patient, two sets of cervical photos (native and with acetic acid) were taken before and 6-12 months after TA. The SCJ and TZ were evaluated independently by three observers according to the WHO nomenclature. When discordances were observed between the type of TZ and SCJ selected by each observer, a corrected TZ was established on the basis of the SCJ categorization. Interobserver agreement for TZ interpretation was evaluated using Cohen's kappa coefficient for agreement between two observers and Fleiss' kappa between three observers. RESULTS Fifty consecutive participants were included in the analysis. Seventy-six percent were interpreted as TZ1-2, and 24% as TZ3 before TA. In 56% of cases, the entire SCJ could not be entirely visualized after TA, thus being recategorized as TZ3. Interobserver agreement was fair for diagnosis before TA (Kappa coefficient, 0.34; 95% CI, 0.27 to 0.45) and moderate for diagnosis after TA (Kappa coefficient, 0.40; 95% CI, 0.30 to 0.50). After TA, 36% progressed from TZ1-2 to TZ3, with a moderate interobserver agreement (Kappa coefficient, 0.44; 95% CI, 0.40 to 0.54). CONCLUSION We observed a shift of the SCJ into the endocervical canal after TA. A significant proportion of participants had TZ 3 after treatment, raising the question of visual inspection with acetic acid's applicability as a first-line follow-up examination method after TA.
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Affiliation(s)
- Christine Balli
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Biomedical Sciences, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Apollinaire Horo
- Unit of Gynecology and Obstetrics, University Hospital (CHU) of Yopougon, Abidjan, Ivory Coast
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Esther Abatsong
- Department of Biomedical Sciences, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Ania Wisniak
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Vassilakos
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Department of Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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Yao Y, Wang W, Liu Y, Yong M, Zhang M, Yang Y, Xu G, Qu D, Zhou H. Efficacy and pregnancy outcomes of focused ultrasound for cervical high-grade squamous intraepithelial lesions. Int J Hyperthermia 2023; 40:2250936. [PMID: 37666493 DOI: 10.1080/02656736.2023.2250936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE To investigate the efficacy and adverse effects of focused ultrasound (FU) in the treatment of high-grade squamous intraepithelial lesions (HSIL) and follow up on pregnancy outcomes in patients. METHODS This retrospective study recruited 57 patients aged 20-40 years with cervical HSIL combined with HR-HPV infection who received FU treatment between September 2019 and April 2022. Clinical data of the patients were obtained from hospital records. HSIL cure rate and cumulative HR-HPV clearance rate were assessed after treatment. Patients were followed up on fertility and pregnancy outcomes after treatment by telephone interviews until April 1, 2023. RESULTS During a 6-month follow-up, the HSIL cure rate was 73.7%, and a statistical difference between CIN2 and CIN3 (75.6% vs. 66.7%, p = 0.713) was not present. HSIL -recurrence was not observed during the follow-up period, and the median follow-up duration was 12 months. The cumulative HR-HPV clearance rates at the 6- and 12-month follow-ups were 56.1% and 75.4%, respectively. The median clearance time of HR-HPV was 6 (95% confidence interval, 5.46-6.54) months. The clearance rate was higher in HPV16/18 than in non-HPV16/18 (86.7% vs. 62.9%, p = 0.038). After treatment, the successful pregnancy rate in patients with fertility intentions and spontaneous abortion rate were 73.9% and 5.9%, respectively. Preterm birth, preterm premature rupture of membranes, or low-birth-weight infants were not observed. CONCLUSION FU treatment can regress HSIL and accelerate HR-HPV clearance in young women of childbearing age with cervical HSIL associated with HR-HPV infection, and has no significant adverse effects on pregnancy outcomes.
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Affiliation(s)
- Yuqin Yao
- North Sichuan Medical College, Sichuan, P.R. China
| | - Wenping Wang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
| | - Yujuan Liu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
| | - Min Yong
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
| | - Miao Zhang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
| | - Yulu Yang
- North Sichuan Medical College, Sichuan, P.R. China
| | - Gan Xu
- North Sichuan Medical College, Sichuan, P.R. China
| | - Dacheng Qu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
| | - Honggui Zhou
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichaun Medical College, Sichuan, P.R. China
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Broquet C, Vassilakos P, Ndam Nsangou FM, Kenfack B, Noubom M, Tincho E, Jeannot E, Wisniak A, Petignat P. Utility of extended HPV genotyping for the triage of self-sampled HPV-positive women in a screen-and-treat strategy for cervical cancer prevention in Cameroon: a prospective study of diagnostic accuracy. BMJ Open 2022; 12:e057234. [PMID: 36549727 PMCID: PMC9791451 DOI: 10.1136/bmjopen-2021-057234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore the utility of extended Human Papillomavirus (HPV) genotyping to detect cervical intraepithelial neoplasia grade 2 or more (CIN2+) in a 'screen-and-treat' strategy for HPV-positive women in low-resource settings. DESIGN Prospective study of diagnostic accuracy. SETTING The study took place in West Cameroon between September 2018 and March 2020. PARTICIPANTS 2014 women were recruited. Asymptomatic, non-pregnant women aged 30-49 years without history of CIN treatment, anogenital cancer or hysterectomy were eligible. INTERVENTIONS Participants performed self-sampling for HPV testing with GeneXpert followed by visual inspection with acetic acid and Lugol's iodine (VIA) triage before treatment if required. MAIN OUTCOME MEASURES Liquid-based cytology, biopsies and endocervical brushing were performed in HPV-positive women as quality control. We assessed the detection rate of CIN2+ by HPV genotyping (two pools of genotypes obtained from the Xpert system, pool_1 (HPV 16, 18, 45) and pool_2 (HPV 16, 18, 45, 31, 33, 35, 52, 58)), VIA and cytology. RESULTS 382 (18.2%) women were HPV-positive among which 11.5% (n=44) were CIN2+. Of those 44 participants, 41 were triaged positive by extended genotyping, versus 35 by VIA and 33 by cytology. Overall, triage positivity was of 68.4% for extended genotyping, 59.3% for VIA and 14.8% for cytology, with false positive rates of 83.4%, 84.1% and 37.7%, respectively. Extended genotyping had a higher sensitivity for CIN2+ detection (93.2%, CI: 81.3 to 98.6) than VIA (79.5%, CI: 64.7 to 90.2, p=0.034) and cytology (75.0%, CI: 59.7 to 86.8, p=0.005). No significant difference was observed in the overtreatment rate in triaged women by extended genotyping or VIA (9.9%, CI: 8.6 to 11.3, and 8.8%, CI: 7.7 to 10.1), with a ratio of 6.0 and 6.3 women treated per CIN2+ diagnosed. CONCLUSION Triage of HPV-positive women with extended HPV genotyping improves CIN2+ detection compared with VIA with a minor loss of specificity and could be used to optimize the management of HPV-positive women. TRIAL REGISTRATION NUMBER NCT03757299.
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Affiliation(s)
- Celine Broquet
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Vassilakos
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - François Marcel Ndam Nsangou
- Department of Gynecology, Obstetrics and Maternal Health, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Bruno Kenfack
- Department of Gynecology, Obstetrics and Maternal Health, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Michel Noubom
- Department of Gynecology, Obstetrics and Maternal Health, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Evelyn Tincho
- Department of Gynecology, Obstetrics and Maternal Health, University of Dschang, Dschang District Hospital, Dschang, Cameroon
| | - Emilien Jeannot
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ania Wisniak
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Patrick Petignat
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
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Soler M, Alfaro K, Masch RJ, Conzuelo Rodriguez G, Qu X, Wu S, Sun J, Hernández Jovel DM, Bonilla J, Puentes LO, Murillo R, Alonzo TA, Felix JC, Castle P, Cremer M. Safety and Acceptability of Three Ablation Treatments for High-Grade Cervical Precancer: Early Data From a Randomized Noninferiority Clinical Trial. JCO Glob Oncol 2022; 8:e2200112. [PMID: 36525620 PMCID: PMC10166394 DOI: 10.1200/go.22.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE This ongoing trial is comparing the efficacy and safety of three ablation treatments for cervical intraepithelial neoplasia grade 2 or higher. Here, we present early data regarding pain, side effects, and acceptability of CO2 gas-based cryotherapy (CO2), nongas cryotherapy, and thermal ablation (TA). Efficacy results are expected to become available in late 2023. MATERIALS AND METHODS This noninferiority randomized trial is taking place in El Salvador, China, and Colombia. Patients are 1,152 eligible women with biopsy-confirmed cervical intraepithelial neoplasia grade 2 or higher who will receive one of three ablation treatments. Pain is measured before, during, and after treatment with a visual analog scale (1-10). Side effects and acceptability are assessed at 6 weeks. RESULTS To date, 1,024 of 1,152 (89%) women were randomly assigned to treatment. The median pain level was higher during TA (4, IQR = 4) than CO2 (2, IQR = 4) or nongas cryotherapy (2, IQR = 4) (P < .01, range: 0-10). The most common post-treatment symptom was watery discharge, reported by 97.9% of women, and it lasted longer in the CO2 group than the other two treatments (in days, median [IQR]: CO2 = 20[20], nongas cryotherapy = 15[10], TA = 18[15], P < .01). Bleeding was reported more frequently in women treated with TA (27.6%) than CO2 (17.5) or nongas cryotherapy (18.7%) (P < .01). The majority of patients reported being very satisfied with the treatment they received at 6 weeks (91%) and again at 12 months post-treatment (97%). CONCLUSION Despite differences in pain and side effects across ablation treatments, all were safe and highly acceptable to patients. In addition to efficacy, considerations such as cost and portability may be more significant in choosing a treatment method.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Karla Alfaro
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Rachel J Masch
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | | | - Xinfeng Qu
- Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
| | - Suhui Wu
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Jingfen Sun
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | | | - Jairo Bonilla
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Luis Orlando Puentes
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Raúl Murillo
- Centro Javeriano de Oncología, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Todd A Alonzo
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Philip Castle
- Divisions of Cancer Prevention and Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH.,Basic Health International, Pittsburgh, PA; San Salvador, El Salvador
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Dzinamarira T, Moyo E, Dzobo M, Mbunge E, Murewanhema G. Cervical cancer in sub-Saharan Africa: an urgent call for improving accessibility and use of preventive services. Int J Gynecol Cancer 2022; 33:592-597. [PMID: 36368710 DOI: 10.1136/ijgc-2022-003957] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Sub-Saharan Africa has the highest rates of cervical cancer in the world, largely attributed to low cervical cancer screening coverage. Cervical cancer is the most common cause of death among women in 21 of the 48 countries in sub-Saharan Africa. Close to 100% of all cases of cervical cancer are attributable to Human papillomavirus (HPV). HPV types 16 and 18 cause at least 70% of all cervical cancers globally, while types 31, 33, 45, 52, and 58 cause a further 20% of the cases. Women living with HIV are six times more likely to develop cervical cancer than those without HIV. Considering that sub-Saharan Africa carries the greatest burden of cervical cancer, ways to increase accessibility and use of preventive services are urgently required. With this review, we discuss the preventive measures required to reduce the burden of cervical cancer in sub-Saharan Africa, the challenges to improving accessibility and use of the preventive services, and the recommendations to address these challenges.
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Affiliation(s)
- Tafadzwa Dzinamarira
- Department of Public Health, University of Pretoria, Pretoria, South Africa
- ICAP at Columbia University, Harare, Zimbabwe
| | - Enos Moyo
- Department of Public Health, Oshakati Medical Centre, Oshakati, Namibia
| | - Mathias Dzobo
- Department of Public Health, University of Pretoria, Pretoria, South Africa
| | - Elliot Mbunge
- Department of Information Technology, University of Eswatini, Kwaluseni, Swaziland
| | - Grant Murewanhema
- Unit of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
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Hämmerli P, Moukam AD, Wisniak A, Sormani J, Vassilakos P, Kenfack B, Petignat P, Schmidt NC. "My motivation was to save": a qualitative study exploring factors influencing motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Reprod Health 2022; 19:133. [PMID: 35668427 PMCID: PMC9167909 DOI: 10.1186/s12978-022-01420-y] [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: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cervical cancer is a major public health issue among women in Cameroon and uptake of screening programs remains a challenge in many low- and middle-income countries. Community healthcare workers can play an important role in promoting cervical cancer services. This study aimed to explore factors affecting the motivation of community healthcare workers in a cervical cancer screening program in Dschang, Cameroon. Methods A qualitative approach including 11 in-depth individual interviews with community healthcare workers was used. The interviews were audio-recorded, transcribed and coded using thematic analysis assisted by ATLAS.ti software. Results Four women and seven men aged between 21 and 77 years old were interviewed. Community healthcare workers had high motivation. Factors affecting motivation were divided into individual and environmental level, based on a theoretical framework. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Conclusions Key interventions to improve motivation among community healthcare workers include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport. Trial registration: Geneva Cantonal Ethics Committee on Human Research (No. 2017-01110) and the Cameroonian National Ethics Committee for Human Health Research (No. 2018/07/1083/CE/CNERSH/SP). Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.
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Affiliation(s)
| | - Alida Datchoua Moukam
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Ania Wisniak
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Jessica Sormani
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland.,Geneva School of Health Sciences, HESSO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Bruno Kenfack
- Department of Gynaecology and Obstetrics, District Hospital of Dschang, Dschang, Cameroon
| | - Patrick Petignat
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicole Christine Schmidt
- Gynaecology Division, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland. .,Faculty of Social Science, Catholic University of Applied Science, Preysingstr. 95, 81667, Munich, Germany.
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A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial. Contemp Clin Trials Commun 2022; 26:100903. [PMID: 35243124 PMCID: PMC8857441 DOI: 10.1016/j.conctc.2022.100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 01/25/2023] Open
Abstract
Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.
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Metaxas T, Kenfack B, Sormani J, Tincho E, Lemoupa Makajio S, Wisniak A, Vassilakos P, Petignat P. Acceptability and safety of thermal ablation to prevent cervical cancer in sub-Saharan Africa. BMC Cancer 2022; 22:132. [PMID: 35109806 PMCID: PMC8812220 DOI: 10.1186/s12885-022-09202-2] [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: 06/26/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background The World Health Organization recommends thermal ablation as an alternative to cryotherapy to treat women with precancerous lesions in low-resource settings. However, limited data are available on women’s experience and adverse events (AEs) of the procedure in the context of Sub-Saharan Africa. The objective of this study was to evaluate the acceptability and safety of thermal ablation in women screened positive for precancerous cervical lesions. Methods Asymptomatic women aged 30–49 years old living in the Dschang Health District were invited to participate in a cervical cancer screening campaign termed “3 T-Approach” (for Test-Triage and Treat). Recruited women were asked to perform HPV self-sampling followed by triage with visual assessment and treatment with thermal ablation if required. After treatment and 4–6 weeks later, interviews were conducted to assess women’s experience on anxiety, discomfort, and pain during thermal ablation. AEs were recorded on pre-defined electronic forms 4–6 weeks after treatment to assess the procedure’s safety. Results Between September 2018 and December 2020, 399 HPV-positive women (18.7% of women screened) were recruited, 236 (59.1%) had a positive visual assessment, 234 were treated by thermal ablation and 198 (84.6%) received therapy in the same visit. Treatment was not considered as painful (score ≤ 4/10) by 209 (90.9%) patients while 5 (2.5%) reported high pain (score 8–10/10). During post-treatment interviews 4–6 weeks later, most reported AEs were graded mild or moderate (grade I-II). The most frequent symptoms reported as mild AEs (grade 1–2) were vaginal watery discharge (75.5%), vaginal bloody-stained discharge (21.5%) and malodourous discharge (14.5%). None of the participants experienced serious AEs (grade 3–4) or AEs requiring admission to hospital or emergency consultation. The vast majority of women (99.6%) would agree to repeat the procedure if necessary and (99.6%) would recommend it to friends or family. Conclusion Thermal ablation is widely accepted by women and appears as a safe procedure. It may contribute to improving the link between screening and treatment in a single visit and to optimizing cervical cancer control in low-resource settings. Trial registration The study was registered on clinicaltrials.gov (NCT03757299) in November 2018 (28/11/2018).
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Affiliation(s)
- Tania Metaxas
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland.
| | - Bruno Kenfack
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Jessica Sormani
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland.,School of Health Sciences Geneva, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
| | - Eveline Tincho
- Faculty of Medicine and Biomedical Sciences, University Teaching Hospital of Yaounde, Yaounde, Cameroon
| | - Sophie Lemoupa Makajio
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
| | - Ania Wisniak
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
| | - Pierre Vassilakos
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Patrick Petignat
- Gynecology Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Boulevard de la Cluse 30, 1205, Geneva, Switzerland
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10
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Soler M, Masch R, Saidu R, Cremer M. Thermal Ablation Treatment for Cervical Precancer (Cervical Intraepithelial Neoplasia Grade 2 or Higher [CIN2+]). Methods Mol Biol 2022; 2394:867-882. [PMID: 35094363 DOI: 10.1007/978-1-0716-1811-0_46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cervical cancer is a leading cause of mortality for women in low- and middle-income countries (LMICs). Invasive disease can be prevented through the treatment of high-grade cervical precancer lesions. Types of treatment for cervical precancer include excisional procedures that surgically remove the affected tissue and ablation treatments which utilize extreme temperatures to destroy precancerous cells. Excision is the first-line treatment in higher income countries, but requires specialized training and equipment that make it unsuitable for low-income settings. The most common treatment globally is cryotherapy, which utilizes cryogenic gas to freeze the area. However, the need for gas presents significant procurement and logistical challenges. The World Health Organization (WHO) has recently endorsed the use of thermal ablation, a method that utilizes heat to destroy precancerous tissue. This review describes three existing thermal ablation devices and protocols for their use, including step-by-step instruction guides to perform a successful treatment with each device and observations specific to each machine.
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Affiliation(s)
- Montserrat Soler
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
- Basic Health International, Pittsburgh, PA, USA.
| | | | - Rakiya Saidu
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Miriam Cremer
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
- Basic Health International, Pittsburgh, PA, USA
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11
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Osintsev AM, Vasilchenko IL, Rodrigues DB, Stauffer PR, Braginsky VI, Rynk VV, Gromov ES, Prosekov AY, Kaprin AD, Kostin AA. Characterization of Ferromagnetic Composite Implants for Tumor Bed Hyperthermia. IEEE TRANSACTIONS ON MAGNETICS 2021; 57:10.1109/tmag.2021.3097915. [PMID: 34538882 PMCID: PMC8443243 DOI: 10.1109/tmag.2021.3097915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Hyperthermia therapy (HT) is becoming a well-recognized method for the treatment of cancer when combined with radiation or chemotherapy. There are many ways to heat a tumor and the optimum approach depends on the treatment site. This study investigates a composite ferromagnetic surgical implant inserted in a tumor bed for the delivery of local HT. Heating of the implant is achieved by inductively coupling energy from an external magnetic field of sub-megahertz frequency. Implants are formed by mechanically filling a resected tumor bed with self-polymerizing plastic mass mixed with small ferromagnetic thermoseeds. Model implants were manufactured and then heated in a 35 cm diameter induction coil of our own design. Experimental results showed that implants were easily heated to temperatures that allow either traditional HT (39-45°C) or thermal ablation therapy (>50°C) in an external magnetic field with a frequency of 90 kHz and amplitude not exceeding 4 kA/m. These results agreed well with a numerical solution of combined electromagnetic and heat transfer equations solved using the finite element method.
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Affiliation(s)
| | - Ilya L Vasilchenko
- Kemerovo State University, Kemerovo, Russia
- Kuzbass Clinical Oncological Dispensary, Kemerovo, Russia
| | | | | | | | | | | | | | - Andrey D Kaprin
- National Medical Research Radiological Center, Moscow, Russia
| | - Andrey A Kostin
- National Medical Research Radiological Center, Moscow, Russia
- Peoples' Friendship University of Russia, Moscow, Russia
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12
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Alfaro K, Maza M, Felix JC, Gage JC, Castle PE, Alonzo TA, Chacón A, González E, Soler M, Conzuelo-Rodriguez G, Masch R, Cremer M. Outcomes for Step-Wise Implementation of a Human Papillomavirus Testing-Based Cervical Screen-and-Treat Program in El Salvador. JCO Glob Oncol 2021; 6:1519-1530. [PMID: 33064628 PMCID: PMC7605377 DOI: 10.1200/go.20.00206] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The Cervical Cancer Prevention in El Salvador (CAPE) project is a public-sector intervention introducing lower-cost human papillomavirus (HPV) testing in all four departments of the Paracentral region that screened a total of 28,015 women. After demonstrating success of an HPV screen-and-treat (S&T) algorithm over colposcopy management in the first two phases, the third phase scaled up the S&T strategy. We present results from phase III and evaluate S&T components across the entire project. METHODS During phase III, 17,965 women age 30-59 years underwent HPV testing. HPV-positive women were asked to return and, if eligible, received gas-based cryotherapy. We compare loss to follow-up and time intervals between S&T steps across the three phases. RESULTS There were no differences in HPV positivity across phases (phase I, 11.9%; phase II, 11.4%; phase III, 12.3%; P = .173). Although most HPV-positive women completed indicated follow-up procedures within 6 months in phases I (93.3%, 111 of 119) and II (92.3%, 429 of 465), this proportion declined to 74.9% (1,659 of 2,214; P < .001) in phase III. Mean days between testing and delivery of results to patients increased over program phases (phase I, 23.2 days; phase II, 46.7 days; phase III, 99.8 days; P < .001). CONCLUSION A public-sector implementation of an HPV-based S&T algorithm was successfully scaled up in El Salvador, albeit with losses in efficiency. After CAPE, the Ministry of Health changed its screening guidelines and procured additional tests to expand the program.
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Affiliation(s)
- Karla Alfaro
- Basic Health International, San Salvador, El Salvador and New York, NY
| | - Mauricio Maza
- Basic Health International, San Salvador, El Salvador and New York, NY
| | - Juan C Felix
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Julia C Gage
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Philip E Castle
- Division of Cancer Prevention and Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH/DHHS, Rockville, MD
| | - Todd A Alonzo
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Andrea Chacón
- Unidad de Cáncer, Ministerio de Salud República de El Salvador, San Salvador, El Salvador
| | - Enrique González
- Unidad de Cáncer, Ministerio de Salud República de El Salvador, San Salvador, El Salvador
| | - Montserrat Soler
- Ob/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | | | - Rachel Masch
- Basic Health International, San Salvador, El Salvador and New York, NY
| | - Miriam Cremer
- Basic Health International, San Salvador, El Salvador and New York, NY.,Ob/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH
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13
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Zhao XL, Liu ZH, Zhao S, Hu SY, Muwonge R, Duan XZ, Du LJ, Su CF, Xiang XE, Zhang X, Pan QJ, Qiao YL, Sankaranarayanan R, Zhao FH, Basu P. Efficacy of point-of-care thermal ablation among high-risk human papillomavirus positive women in China. Int J Cancer 2021; 148:1419-1427. [PMID: 32895912 DOI: 10.1002/ijc.33290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 08/17/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023]
Abstract
Thermal ablation is a point-of-care ablative treatment technique for cervical intraepithelial neoplasia (CIN). However, limited information is available about its efficacy in low- and middle-income countries. We evaluated the efficacy of thermal ablation in treatment of CIN detected through high-risk human papillomavirus (HPV) screening in China. Women positive on high-risk HPV and having colposcopically suspected lesions eligible for ablation underwent colposcopy, biopsy and thermal ablation in one visit. Women ineligible were recalled for large loop excision of transformation zone (LLETZ) when histopathology results were high-grade CIN. Posttreatment follow-up at 6 months or more was with HPV test and cytology followed by colposcopy and biopsy for HPV and/or cytology-positive women. Cure was defined as either negative cytology and HPV test or absence of histopathology proved CIN in any positive women. Of total 218 HPV-positive women treated with thermal ablation (n = 170) or LLETZ (n = 48), 196 reported for follow-up evaluation. For women with histologically confirmed CIN at baseline (thermal ablation-104; LLETZ-38), cure rates were 84.6% for thermal ablation and 86.8% for LLETZ. Cure rates after thermal ablation were 90.3% for CIN grade one (CIN1) and 76.2% for CIN grade two or worse (CIN2+). HPV clearance rate was 80.4% in women undergoing thermal ablation, which was lower for HPV16/18 compared to other oncogenic types (67.6% vs 85.7%). HPV test had a negative predictive value (NPV) of 98.7% to detect CIN2+ at follow-up and the positive predictive value (PPV) was 40.4%. Thermal ablation is effective to treat CIN as well as to clear the high-risk HPV infection. HPV test has high PPV and NPV in following up patients posttreatment.
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Affiliation(s)
- Xue-Lian Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Hua Liu
- Department of Gynecology, Affiliated Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Shaung Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shang-Ying Hu
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Xian-Zhi Duan
- Department of Obstetrics and Gynecology, Beijing Tongren Hospital, Beijing, China
| | - Li-Jun Du
- Department of Obstetrics and Gynecology, Erdos Maternal and Child Health Care Hospital, Erdos, Inner Mongolia, China
| | - Cai-Feng Su
- Department of Gynecology, Xiangyuan Maternal and Child Health Care Hospital, Changzhi, Shanxi, China
| | - Xi-E Xiang
- Department of Gynecology, Xiangyuan Maternal and Child Health Care Hospital, Changzhi, Shanxi, China
| | - Xun Zhang
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin-Jing Pan
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - You-Lin Qiao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rengaswamy Sankaranarayanan
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
- Senior Medical Advisor, RTI (Research Triangle Institute) International, New Delhi, India
| | - Fang-Hui Zhao
- Department of Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France
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14
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de Fouw M, Oosting RM, Rutgrink A, Dekkers OM, Peters AAW, Beltman JJ. A systematic review and meta-analysis of thermal coagulation compared with cryotherapy to treat precancerous cervical lesions in low- and middle-income countries. Int J Gynaecol Obstet 2019; 147:4-18. [PMID: 31273785 DOI: 10.1002/ijgo.12904] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 05/09/2019] [Accepted: 07/03/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thermal coagulation is gaining popularity for treating cervical intraepithelial neoplasia (CIN) in screening programs in low- and middle-income countries (LMICs) due to unavailability of cryotherapy. OBJECTIVES Assess the effectiveness of thermal coagulation for treatment of CIN lesions compared with cryotherapy, with a focus on LMICs. SEARCH STRATEGY Papers were identified from previous reviews and electronic literature search in February 2018 with publication date after 2010. SELECTION CRITERIA Publications with original data evaluating cryotherapy or thermal coagulation with proportion of cure as outcome, assessed by colposcopy, biopsy, cytology, and/or visual inspection with acetic acid (VIA), and minimum 6 months follow-up. DATA COLLECTION AND ANALYSIS Pooled proportions of cure are presented stratified per treatment modality, type of lesion, and region. MAIN RESULTS Pooled cure proportions for cryotherapy and thermal coagulation, respectively, were 93.8% (95% CI, 88.5-97.7) and 91.4% (95% CI, 84.9-96.4) for CIN 1; 82.6% (95% CI, 77.4-87.3) and 91.6% (95% CI, 88.2-94.5) for CIN 2-3; and 92.8% (95% CI, 85.6-97.7) and 90.1% (95% CI, 87.0-92.8) for VIA-positive lesions. For thermal coagulation of CIN 2-3 lesions in LMICs 82.4% (95% CI, 75.4-88.6). CONCLUSIONS Both cryotherapy and thermal coagulation are effective treatment modalities for CIN lesions in LMICs.
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Affiliation(s)
- Marlieke de Fouw
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Roos Marieke Oosting
- Department of BioMechanical Engineering, Delft University of Technology, Delft, Netherlands
| | - Amy Rutgrink
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
| | - Olaf Matthijs Dekkers
- Department of Clinical Epidemiology and Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jogchum Jan Beltman
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, Netherlands
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Cervical Cancer Screening Beliefs and Prevalence of LSIL/HSIL Among a University-Based Population in Cameroon. J Low Genit Tract Dis 2018; 22:274-279. [DOI: 10.1097/lgt.0000000000000433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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