The road ahead for cervical cancer prevention and control

Male Circumcision and Genital Human Papillomavirus (HPV) Infection in Males and Their Female Sexual Partners: Findings From the HPV Infection and Transmission Among Couples Through Heterosexual Activity (HITCH) Cohort Study

BACKGROUND

Previous studies examining the association between male circumcision (MC) and human papillomavirus (HPV) infections have reported inconsistent results. We used data from the HPV Infection and Transmission Among Couples Through Heterosexual Activity (HITCH) cohort study to examine the association between MC and HPV infections in males and their female sexual partners.

METHODS

We enrolled monogamous couples in a longitudinal study between 2005 and 2011 in Montreal, Canada. We used logistic and Poisson regression models with propensity score adjustment to estimate odds ratios (ORs) and rate ratios for the association between MC and the prevalence, transmission, and clearance of HPV infections.

RESULTS

Four hundred thirteen couples were included in our study. The prevalence OR for the association between MC and baseline infections was 0.81 (95% confidence interval [CI], .56-1.16) in males and 1.05 (95% CI, .75-1.46) in females. The incidence rate ratio for infection transmission was 0.59 (95% CI, .16-2.20) for male-to-female transmission and 0.77 (95% CI, .37-1.60) for female-to-male transmission. The clearance rate ratio for clearance of infections was 0.81 (95% CI, .52-1.24).

CONCLUSIONS

We found little evidence of an association between MC and HPV infection prevalence, transmission, or clearance in males and females. Further longitudinal couple-based studies are required to investigate this association.

Burden of Cervical Cancer in the Eastern Mediterranean Region During the Years 2000 and 2017: Retrospective Data Analysis of the Global Burden of Disease Study

BACKGROUND

Cervical cancer is a growing health concern, especially in resource-limited settings.

OBJECTIVE

The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally between the years 2000 and 2017 by using a pooled data analysis approach.

METHODS

We used an ecological approach at the country level. This included extracting data from publicly available databases and linking them together in the following 3 steps: (1) extraction of data from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2) categorization of EMR countries according to the World Bank gross domestic product per capita, and (3) linking age-specific population data from the Population Statistics Division of the United Nations (20-29 years, 30-49 years, and >50 years) and GBD's data with gross national income per capita and globally extracted data, including cervical cancer mortality and DALY numbers and rates per country. The cervical cancer mortality rate was provided by the GBD study using the following formula: number of cervical cancer deaths × 100,000/female population in the respective age group.

RESULTS

The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326) to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this disease decreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). According to age-specific data, the age group ≥50 years showed the highest mortality rate in both EMR countries and globally, and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR were lower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rate per 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000; respectively). However, the relative difference in the number of DALYs due to cervical cancer between the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9 vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively).

CONCLUSIONS

We found an increase in the burden of cervical cancer in the EMR as per the data on the absolute number of deaths and DALYs. Further, we found that the health care system has an increased number of cases to deal with, despite the decrease in the absolute number of deaths and DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and early screening is performed. Therefore, we recommend identifying effective vaccination programs and interventions to reduce the burden of this disease.

Impact of knowledge and attitude on the utilization rate of cervical cancer screening tests among Ethiopian women: A systematic review and meta-analysis

INTRODUCTION

Cervical cancer is a major public health problem, particularly in resource-limited settings. The use of vaccination and screening tests has reduced the burden of cervical cancer in developed countries. However, the situation is quite the reverse in developing countries, including Ethiopia. Hence, this study aimed to estimate the pooled impact of knowledge and attitude on the prevalence of cervical cancer screening service utilization rates among Ethiopian women.

METHODS

Studies that examined cervical cancer screening service utilization among women in Ethiopia were searched from five international databases. Cochran's Q chi-square and the I-squared test statistics were used to check the presence of heterogeneity among the included studies. The funnel plot and Egger's regression tests were also used to assess the presence of publication bias. A weighted DerSimonian and Laird random-effects model was employed. Subgroup analysis was performed by the study population concerning the prevalence of cervical cancer screening service utilization rates. Sensitivity analysis was also conducted to assess the effect of a single study on the pooled estimates. Data analysis was performed using STATA™ Version 14 software.

RESULTS

A total of 44 studies with 28,186 study participants were included. The estimated pooled prevalence of cervical cancer screening service utilization was 8.11% (95% CI: 7.26, 8.97). After adjustment for publication bias with the trim and fill analysis, the estimated prevalence rate appeared to be 5.47% (95% CI: 4.66, 6.28). The prevalence of cervical cancer screening service utilization was higher among HIV-positive women, 16.85%, and in studies conducted among health care workers, 10.24%, than the general population. The pooled effect of knowledge on the utilization of cervical cancer screening tests among Ethiopian women was statistically significant (AOR = 3.20, 95% CI: 1.63, 6.31). Similarly, the pooled estimated odds of utilizing cervical cancer screening tests were 6.1 times higher (AOR = 6.09, 95% CI: 1.09, 34.36) among women who had a favorable attitude towards the screening tests.

CONCLUSION

Knowledge and attitude had a significant impact on the prevalence of cervical cancer screening test utilization rates among women in Ethiopia. However, the prevalence of cervical cancer screening service utilization among Ethiopian women is very low. Hence, large-scale awareness programs and situation-based strategies need to be designed to increase the uptake of cervical cancer screening services in the country.

Mailed self-sample HPV testing kits to improve cervical cancer screening in a safety net health system: protocol for a hybrid effectiveness-implementation randomized controlled trial

BACKGROUND

Almost 20% of U.S. women remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation.

METHODS/DESIGN

The Prospective Evaluation of Self-Testing to Increase Screening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2268 participants randomized to telephone recall (enhanced usual care, n = 756), telephone recall with mailed self-sample HPV testing kit (intervention, n = 756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n = 756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness.

DISCUSSION

Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform screening strategies to ultimately realize the global goal of eliminating cervical cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898167 . Registered on 01 April 2019.

TRIAL STATUS

Study start data: February 13, 2020. Recruitment status: Enrolling by invitation. Estimated primary completion date: February 15, 2023. Estimated study completion date: May 31, 2024. Protocol version 1.6 (February 25, 2020).

Annona coriacea Mart. Fractions Promote Cell Cycle Arrest and Inhibit Autophagic Flux in Human Cervical Cancer Cell Lines

Plant-based compounds are an option to explore and perhaps overcome the limitations of current antitumor treatments. Annona coriacea Mart. is a plant with a broad spectrum of biological activities, but its antitumor activity is still unclear. The purpose of our study was to determine the effects of A. coriacea fractions on a panel of cervical cancer cell lines and a normal keratinocyte cell line. The antitumor effect was investigated in vitro by viability assays, cell cycle, apoptosis, migration, and invasion assays. Intracellular signaling was assessed by Western blot, and major compounds were identified by mass spectrometry. All fractions exhibited a cytotoxic effect on cisplatin-resistant cell lines, SiHa and HeLa. C3 and C5 were significantly more cytotoxic and selective than cisplatin in SiHa and Hela cells. However, in CaSki, a cisplatin-sensitive cell line, the compounds did not demonstrate higher cytotoxicity when compared with cisplatin. Alkaloids and acetogenins were the main compounds identified in the fractions. These fractions also markedly decreased cell proliferation with p21 increase and cell cycle arrest in G2/M. These effects were accompanied by an increase of H2AX phosphorylation levels and DNA damage index. In addition, fractions C3 and C5 promoted p62 accumulation and decrease of LC3II, as well as acid vesicle levels, indicating the inhibition of autophagic flow. These findings suggest that A. coriacea fractions may become effective antineoplastic drugs and highlight the autophagy inhibition properties of these fractions in sensitizing cervical cancer cells to treatment.

What benefits and harms are important for a decision about cervical screening? A study of the perspective of different subgroups of women

Background: In cervical screening programs, women typically receive information leaflets to support their decision about participation. However, these leaflets are often based on what experts consider important benefits and harms of screening and not what women themselves consider important to know. Objective: To identify which benefits and harms women consider important for making a decision about cervical screening. Design: Cross-sectional study. Setting and participants: Women from the Dutch target group of cervical screening (N=248; 30-60 years), recruited through an online access panel. Main variables studied: Perceived importance of different benefits and harms of cervical screening, assessed through two rating items ("How important is the information about [this harm/benefit] for your decision?" and "For me it is a [benefit/harm] that participating in the screening program leads to [the benefit/harm]"), and one ranking item ("Rank the information according to their importance for your own choice"). Results: Women overall considered the benefits of cervical screening more important than the harms or disadvantages. The most important harm according to women was the chance of false positive results (M=4.88; SD=1.75). Differences between those with lower and higher numeracy/health literacy were found regarding several aspects, e.g. for the chance of false positive results, the chance of false negative results, the chance of overtreatment. Discussion and conclusion: The results suggest that leaflets could include more explicit information about false positive results.

Achieving high uptake of human papillomavirus vaccination in Malaysia through school-based vaccination programme

BACKGROUND

In 2006, 4 years of planning was started by the Ministry of Health, Malaysia (MOH), to implement the HPV (human papillomavirus) vaccination programme. An inter-agency and multi-sectoral collaborations were developed for Malaysia's HPV school-based immunisation programme. It was approved for nationwide school base implementation for 13-year-old girls or first year secondary students in 2010. This paper examines how the various strategies used in the implementation over the last 7 years (2010-2016) that unique to Malaysia were successful in achieving optimal coverage of the target population.

METHODS

Free vaccination was offered to school girls in secondary school (year seven) in Malaysia, which is usually at the age of 13 in the index year. All recipients of the HPV vaccine were identified through school enrolments obtained from education departments from each district in Malaysia. A total of 242,638 girls aged between 12 to 13 years studying in year seven were approached during the launch of the program in 2010. Approximately 230,000 girls in secondary schools were offered HPV vaccine per year by 646 school health teams throughout the country from 2010 to 2016.

RESULTS

Parental consent for their daughters to receive HPV vaccination at school was very high at 96-98% per year of the programme. Of those who provided consent, over 99% received the first dose each year and 98-99% completed the course per year. Estimated population coverage for the full vaccine course, considering also those not in school, is estimated at 83 to 91% per year. Rates of adverse events reports following HPV vaccination were low at around 2 per 100,000 and the majority was injection site reactions.

CONCLUSION

A multisectoral and integrated collaborative structure and process ensured that the Malaysia school-based HPV immunisation programme was successful and sustained through the programme design, planning, implementation and monitoring and evaluation. This is a critical factor contributing to the success and sustainability of the school-based HPV immunisation programme with very high coverage.

Escalated radiation and prophylactic extended field nodal irradiation are beneficial for FIGO IIIB cervical cancer patients' prognosis

Background

Currently, the standard treatment for locally advanced cervical cancer patients is concurrent chemoradiotherapy. Here we aim to evaluate therapeutic efficacy, treatment failure, toxicity and prognostic factors for FIGO IIIB cervical cancer patients.

Methods

A comprehensive retrospective analysis was performed to understand various factors which contribute to IIIB cervical cancer prognosis. In total 223 well defined patients were assigned according to their pathological subtype, age, pre-treatment HGB level, tumor size, pelvic lymph node (LN) metastasis, para-aortic LN metastasis as well as external irradiation technologies, treatment duration, point A EQD2 dose and concurrent chemotherapy cycles. We then performed correlation studies of these factors and OS, DFS, LCR, DMFS using univariate and multivariate analysis respectively.

Results

We managed to achieve 207 (92.8%) complete response (CR) and 16 (7.2%) partial response (PR) with acceptable adverse effects. Notably, the 5 years OS, DFS, LCR, DMFS for these patients were 61.1, 55.2, 83.6 and 66.4% respectively. Importantly, our studies suggest that escalated point A EQD2 can significantly improve OS, DFS and LCR for FIGO IIIB cervical cancer patients, furthermore, patients without para-aortic LN metastasis who received prophylactic extended field irradiation have significant survival advantage for DFS and a tendency to improve OS and DMFS.

Conclusions

Our results suggest that FIGO IIIB cervical cancer patients should receive higher EQD2 (≥98Gy₁₀) radiotherapy, moreover, patients without para-aortic LN metastasis should receive prophylactic extended field nodal irradiation to improve prognosis.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1172-1) contains supplementary material, which is available to authorized users.

Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review

INTRODUCTION

Vaccine herd effects are the indirect protection that vaccinated persons provide to those who remain susceptible to infection, due to the reduced transmission of infections. Herd effects have been an important part of the discourse on how to best implement human papillomavirus (HPV) vaccines and prevent HPV-related diseases.

AREAS COVERED

In this paper, we review the theory of HPV vaccine herd effects derived from mathematical models, give an account of observed HPV vaccine herd effects worldwide, and examine the implications of vaccine herd effects for future cervical cancer screening efforts.

EXPERT COMMENTARY

HPV vaccine herd effects improve the cost-effectiveness of vaccinating preadolescent girls, but contribute to making gender-neutral vaccination less economically efficient. Vaccination coverage and sexual mixing patterns by age are strong determinants of herd effects. Many countries worldwide are starting to observe reductions in HPV-related outcomes likely attributable to herd effects, most notably declining anogenital warts in young men, and declining HPV-16/18 infection prevalence in young unvaccinated women. Policy makers making recommendations for cervical cancer screening will have to consider HPV vaccination coverage and herd effects, as these will affect the positive predictive value of screening and the risk of cervical cancer in unvaccinated women.

Candidate biomarkers in the cervical vaginal fluid for the (self-)diagnosis of cervical precancer

Purpose

Despite improvement in vaccines against human papilloma virus (HPV), the causative agent of cervical cancer, screening women for cervical precancer will remain indispensable in the coming 30–40 years. A simple test that could be performed at home or at a doctor’s practice and that informs the woman whether she is at risk would significantly help make a broader group of patients who aware that they need medical treatment. Cervical vaginal fluid (CVF) is a body fluid that is very well suited for such a test.

Methods

Narrative review of cervical (pre)cancer candidate biomarkers from cervicovaginal fluid, is based on a detailed review of the literature. We will also discuss the possibilities that these biomarkers create for the development of a self-test or point-of-care test for cervical (pre)cancer.

Results

Several DNA, DNA methylation, miRNA, and protein biomarkers were identified in the cervical vaginal fluid; however, not all of these biomarkers are suited for development of a simple diagnostic assay.

Conclusions

Proteins, especially alpha-actinin-4, are most suited for development of a simple assay for cervical (pre)cancer. Accuracy of the test could further be improved by combination of several proteins or by combination with a new type of biomarker, e.g., originating from the cervicovaginal microbiome or metabolome.

Amplification of specific chromosomal regions assessed by fluorescent in situ hybridization on Pap smears to be added as screening tool for identifying women at risk of progressing to cervical cancer

Cervical carcinoma is a frequent malignancy in developing countries despite being a preventable disease. For the first time, four screening tests were used simultaneously for identifying women with a risk of developing cervical cancer, to help clinicians and policy makers to implement the best strategy for reducing the burden of this disease. Women visiting a hospital in India were enrolled after institutional ethics clearance and informed consent. Visual inspection using acetic acid and Pap smear tests were performed on 2683 women, and 104 had abnormal cytology: atypical squamous cells of undetermined significance (n = 29), low-grade squamous intraepithelial lesion (n = 41), high-grade squamous intraepithelial lesion (n = 17), and squamous cell carcinoma (n = 17). These and 96 samples, with normal cytology, were subjected to high-risk human papilloma virus testing and fluorescent in situ hybridization evaluation. Women with abnormal cytology were followed for 5 years and evaluated with colposcopy-guided biopsy. Three accepted methods of screening and one novel fluorescent in situ hybridization assay were carried out in 200 cases. Cutoffs for fluorescent in situ hybridization were established. The screening methods had 88%-96% negative predictive value, while positive predictive value was low (20%) for visual inspection using acetic acid, 47% for fluorescent in situ hybridization, 56% for high-risk human papilloma virus, and 73% for combined high-risk human papilloma virus and fluorescent in situ hybridization. Combined high-risk human papilloma virus and fluorescent in situ hybridization had 94% sensitivity, specificity, and negative predictive value, suggesting that simultaneous screening with these two tests is appropriate for identifying women progressing to cervical cancer and not visual inspection using acetic acid, which has low positive predictive value and Pap cytology which requires to be repeated. Policy makers and clinicians can assess feasibility of incorporating this screening strategy to prevent cervical cancer.

Utility of gene methylation analysis, cytological examination, and HPV-16/18 genotyping in triage of high-risk human papilloma virus-positive women

In 2015, the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening, suggesting triage of women positive for high-risk human papillomavirus (hrHPV) by HPV-16/18 genotyping and cytology for women positive for non-16/18 hrHPV. The design of the present study was based on this interim guidance and analysis of the methylation status of specific candidate genes, which has been proposed as a tool to reduce unnecessary referral following primary HPV screening for cervical cancer. We performed a hospital-based case-control study including 312 hrHPV-positive women. hrHPV genotyping was performed by nested multiplex PCR assay with type-specific primers.Residual cervical cells from liquid-based cytology were used for extraction of genomic DNA for assessment of the methylation status of PAX1, ZNF582, SOX1, and NKX6-1 and HPV genotyping. Combined with HPV-16/18 genotyping, both a dual methylation test for PAX1/ZNF582 and testing for ZNF582 methylation demonstrated 100% association of methylation with pathology results, indicating carcinoma in situ or squamous cell carcinoma. The sensitivity and specificity of the dual methylation test for PAX1/ZNF582 as a reflex test for identification of CIN3+ lesions were 78.85% and 73.55% (odds ratio = 10.37, 95% confidence interval = 4.76-22.58), respectively. This strategy could reduce the number of patients referred for colposcopic examination by 31.3% compared with cytology, and thus provide a feasible follow-up solution in regions where colposcopy is not readily available. This strategy could also prevent unnecessary anxiety in women with hrHPV infection.

First-void urine: A potential biomarker source for triage of high-risk human papillomavirus infected women

Great interest has been directed towards the use of first-void urine as a liquid biopsy for high-risk human papillomavirus DNA testing. Despite the high correlations established between urinary and cervical infections, human papillomavirus testing is unable to distinguish between productive and transforming high-risk infections that have the tendency to progress to cervical cancer. Thus far, investigations have been primarily confined to the identification of biomarkers for triage of high-risk human papillomavirus-positive women in cervicovaginal specimens and tissue biopsies. This paper reviews urinary biomarkers for cervical cancer and triage of high-risk human papillomavirus infections and elaborates on the opportunities and challenges that have emerged regarding the use of first-void urine as a liquid biopsy for the analysis of both morphological- (conventional cytology and novel immunohistochemical techniques) and molecular-based (HPV16/18 genotyping, host/viral gene methylation, RNA, and proteins) biomarkers. A literature search was performed in PubMed and Web of Science for studies investigating the use of urine as a biomarker source for cervical cancer screening. Five studies were identified reporting on biomarkers that are still in preclinical exploratory or clinical assay development phases and on assessments of non-invasive (urine) samples. Although large-scale validation studies are still needed, we conclude that methylation of both host and viral genes in urine has been proven feasible for use as a molecular cervical cancer triage and screening biomarker in phase two studies. This is especially promising and underscores our hypothesis that human papillomavirus DNA and candidate human and viral biomarkers are washed away with the initial, first-void urine, together with exfoliated cells, debris and impurities that line the urethra opening. Similar to the limitations of self-collected cervicovaginal samples, first-void urine will likely not fulfil the high-quality cellularity standards required for morphological biomarkers. Molecular biomarkers will likely overcome this issue to yield high-throughput, objective, and reproducible results. When using proper sampling, transport, storage, preanalytical biomarker concentration techniques, and clinically validated assays, first-void urine is expected to be a valuable source of molecular biomarkers for cervical cancer screening. Furthermore, as first-void urine can be easily and non-invasively collected, it is a highly preferred technique among women and offers the ability to test both primary high-risk human papillomavirus and biomarkers in the same sample. In addition, the use of first-void urine confers opportunities to reduce loss-to follow-up and non-adherence to screening subjects.

Cervical Cancer Screening in Resource-Constrained Countries: Current Status and Future Directions

Cervical cancer continues to be a major public health problem affecting large numbers of women in many developing countries. Limitations of various screening modalities and the lack of ready availability of a cost-effective point-of-care screening tool have hindered the efficient implementation of population-based screening programs in these settings. It has not proved possible for many countries to adopt cytology as a screening modality due to inadequate infrastructure and trained manpower. However, recent developments, notably design and testing of a low-cost HPV test kit and initiatives by countries like India in developing and putting into operation a framework for large-scale screening of women, have raised hopes that cervical cancer control may be possible even in resource-constrained locations. With the advent of HPV vaccination, primary prevention of cervical cancer also seems a distinct possibility. However, wide availability and acceptability of vaccination is still an unresolved issue for developing countries. The possible future effects of vaccination on test characteristics of various screening strategies also need to be evaluated. This review gathers information on the current status of cervical cancer screening with a special focus on low resource settings. It revisits the strengths and limitations of the available screening modalities for cervical cancer viz. cytology, visual methods and HPV testing, in the context of their applicability in developing countries. In addition, the role of newer HPV-detection methods, for instance DNA, RNA and protein-based techniques, in triage of screen-positive women is discussed. The contemporary issue of impact of HPV vaccination on cervical cancer screening is also addressed briefly. The main highlight of the review is the reference to ‘operational framework guidelines’ for population-based cervical cancer screening, which have recently been formulated and are in the process of being implemented in India. The guidelines may serve as a model for other similar low-resource settings where implementation of cancer screening is desired.

Introduction of molecular HPV testing as the primary technology in cervical cancer screening: Acting on evidence to change the current paradigm

Since being introduced in the 1940s, cervical cytology - despite its limitations - has had unequivocal success in reducing cervical cancer burden in many countries. However, we now know that infection with human papillomavirus (HPV) is a necessary cause of cervical cancer and there is overwhelming evidence from large-scale clinical trials, feasibility studies and real-world experience that supports the introduction of molecular testing for HPV as the primary technology in cervical cancer screening (i.e., "HPV primary screening"). While questions remain about the most appropriate age groups for screening, screening interval and triage approach, these should not be considered barriers to implementation. Many countries are in various stages of adopting HPV primary screening, whereas others have not taken any major steps towards introduction of this approach. As a group of clinical experts and researchers in cervical cancer prevention from across Canada, we have jointly authored this comprehensive examination of the evidence to implement HPV primary screening. Our intention is to create a common understanding among policy makers, agencies, clinicians, researchers and other stakeholders about the evidence concerning HPV primary screening to catalyze the adoption of this improved approach to cervical cancer prevention. With the first cohort of vaccinated girls now turning 21, the age when routine screening typically begins, there is increased urgency to introduce HPV primary screening, whose performance may be less adversely affected compared with cervical cytology as a consequence of reduced lesion prevalence post-vaccination.

Systematic review of cost-effectiveness analyses for combinations of prevention strategies against human papillomavirus (HPV) infection: a general trend

BACKGROUND

Due to the arrival of multi-valent HPV vaccines, it is more and more important to have a better understanding of the relationship between vaccination and screening programmes. This review aimed to: (1) collect published evidence on the cost-effectiveness profile of different HPV prevention strategies and, in particular, those combining vaccination with changes in screening practices; (2) explore the cost-effectiveness of alternative preventive strategies based on screening and vaccination.

METHODS

A systematic literature review was conducted in order to identify the relevant studies regarding the cost-effectiveness of prevention strategies against HPV infection. Analysis comparing the modelling approaches between studies was made along with an assessment of the magnitude of impact of several factors on the cost-effectiveness of different screening strategies.

RESULTS

A total of 18 papers were quantitatively summarised within the narrative. A high degree of heterogeneity was found in terms of how HPV prevention strategies have been assessed in terms of their economic and epidemiological impact, with variation in screening practice and valence of HPV vaccination found to have large implications in terms of cost-effectiveness.

CONCLUSIONS

This review demonstrated synergies between screening and vaccination. New prevention strategies involving multi-valence vaccination, HPV DNA test screening, delayed commencement and frequency of screening could be implemented in the future. Strategies implemented in the future should be chosen with care, and informed knowledge of the potential impact of all possible prevention strategies. Highlighted in this review is the difficulty in assessing multiple strategies. Appropriate modelling techniques will need to be utilised to assess the most cost-effective strategies.

Estimating the cost-effectiveness profile of a universal vaccination programme with a nine-valent HPV vaccine in Austria

BACKGROUND

HPV is a major cancer-causing factor in both sexes in the cervix, vulva, vagina, anus, penis, oropharynx as well as the causal factor in other diseases such as genital warts and recurrent respiratory papillomatis. In the context of the arrival of a nonavalent HPV vaccine (6/11/16/18/31/33/45/52/58), this analysis aims to estimate the public health impact and the incremental cost-effectiveness of a universal (girls and boys) vaccination program with a nonavalent HPV vaccine as compared to the current universal vaccination program with a quadrivalent HPV vaccine (6/11/16/18), in Austria.

METHOD

A dynamic transmission model including a wide range of health and cost outcomes related to cervical, anal, vulvar, vaginal diseases and genital warts was calibrated to Austrian epidemiological data. The clinical impact due to the 5 new types was included for cervical and anal diseases outcomes only. In the base case, a two-dose schedule, lifelong vaccine type-specific protection and a vaccination coverage rate of 60% and 40% for girls and boys respectively for the 9-year old cohorts were assumed. A cost-effectiveness threshold of €30,000/QALY-gained was considered.

RESULTS

Universal vaccination with the nonavalent vaccine was shown to reduce the incidence of HPV16/18/31/33/45/52/58 -related cervical cancer by 92%, the related CIN2/3 cases by 96% and anal cancer by 83% and 76% respectively in females and males after 100 years, relative to 75%, 76%, 80% and 74% with the quadrivalent vaccine, respectively. Furthermore, the nonavalent vaccine was projected to prevent an additional 14,893 cases of CIN2/3 and 2544 cases of cervical cancer, over 100 years. Depending on the vaccine price, the strategy was shown to be from cost-saving to cost-effective.

CONCLUSION

The present evaluation showed that vaccinating 60% of girls and 40% of boys aged 9 in Austria with a 9-valent vaccine will substantially reduce the incidence of cervical cancer, CIN and anal cancer compared to the existing strategy. The vaccination strategies performed with the 9-valent vaccine in the current study were all found to be cost-effective compared to the current quadrivalent vaccination strategy by considering a cost-effectiveness threshold of 30,000€/QALY gained.

Framing preventive care messaging and cervical cancer screening in a health-insured population in South Africa: Implications for population-based communication?

The impact of health message framing on cervical cancer screening uptake is poorly understood. In a prospective randomized control study with 748 females, aged 21–65 years with no Pap smear in the previous 3 years, they randomly received a loss-framed, gain-framed, or neutral health message (control) regarding cervical cancer screening by email. Screening rate in the control group was 9.58 percent (CI: 9.29%–9.87%), 5.71 percent (CI: 5.48%–6.98%) in the gain-framed group, and 8.53 percent (CI: 8.24%–8.81%) in the loss-framed group. Statistically there was no difference between the three screening rates. Framing of health messages may not be a significant consideration when communicating through emails.

HPV-FASTER: broadening the scope for prevention of HPV-related cancer

Human papillomavirus (HPV)-related screening technologies and HPV vaccination offer enormous potential for cancer prevention, notably prevention of cervical cancer. The effectiveness of these approaches is, however, suboptimal owing to limited implementation of screening programmes and restricted indications for HPV vaccination. Trials of HPV vaccination in women aged up to 55 years have shown almost 90% protection from cervical precancer caused by HPV16/18 among HPV16/18-DNA-negative women. We propose extending routine vaccination programmes to women of up to 30 years of age (and to the 45-50-year age groups in some settings), paired with at least one HPV-screening test at age 30 years or older. Expanding the indications for HPV vaccination and much greater use of HPV testing in screening programmes has the potential to accelerate the decline in cervical cancer incidence. Such a combined protocol would represent an attractive approach for many health-care systems, in particular, countries in Central and Eastern Europe, Latin America, Asia, and some more-developed parts of Africa. The role of vaccination in women aged >30 years and the optimal number of HPV-screening tests required in vaccinated women remain important research issues. Cost-effectiveness models will help determine the optimal combination of HPV vaccination and screening in public health programmes, and to estimate the effects of such approaches in different populations.

Humoral Immune Response Against Human Papillomavirus as Source of Biomarkers for the Prediction and Detection of Cervical Cancer

Cervical cancer (CC) is one of the main causes of death among women of reproductive age. Although there are different tests, the disease tends to be diagnosed at late stages. In recent years, the use of complementary tests or sequential diagnostic tests has been implemented. Nevertheless, the results are variable and not conclusive; therefore, more studies for improving the usefulness of these tests in diagnostics are necessary. The human papillomavirus (HPV) infection has been associated with both benign and malignant proliferation of skin and mucosal tissues. Furthermore, some HPV types have been classified as high risk due to their potential to cause cancer, and HPV16 is most frequently associated with this disease. Although between 70% and 80% of precancerous lesions are eliminated by the host's immune system, there is no available test to distinguish between regressive lesions from those that could progress to CC. An HPV infection generates a humoral immune response against L1 and L2 capsid proteins, which can be protective and a response against early proteins. The latter is not a protective response, but these antibodies can be used as markers to determine the stage of the infection and/or the stage of the cervical lesion. Up to now, the humoral immune response resulting from the HPV infection has been used to study the biology of the virus and the efficacy of the HPV vaccines. Although there are no conclusive results regarding the use of these antibodies for diagnosis, we hereby review the actual panorama of the antibody response against the HPV proteins during the development of the disease as well as their possible use as biomarkers for the progression of cervical lesions and of CC.

Increasing Cervical Cancer Awareness and Screening in Jamaica: Effectiveness of a Theory-Based Educational Intervention

Despite declines in cervical cancer mortality in developed countries, cervical cancer incidence and mortality rates remain high in Jamaica due to low levels of screening. Effective interventions are needed to decrease barriers to preventive behaviors and increase adoption of behaviors and services to improve prospects of survival. We enrolled 225 women attending health facilities in an intervention consisting of a pre-test, educational presentation and post-test. The questionnaires assessed attitudes, knowledge, risk factors, and symptoms of cervical cancer among women. Changes in knowledge and intention to screen were assessed using paired t-tests and tests for correlated proportions. Participants were followed approximately six months post-intervention to determine cervical cancer screening rates. We found statistically significant increases from pre-test to post-test in the percentage of questions correctly answered and in participants’ intention to screen for cervical cancer. The greatest improvements were observed in responses to questions on knowledge, symptoms and prevention, with some items increasing up to 62% from pre-test to post-test. Of the 123 women reached for follow-up, 50 (40.7%) screened for cervical cancer. This theory-based education intervention significantly increased knowledge of and intention to screen for cervical cancer, and may be replicated in similar settings to promote awareness and increase screening rates.

A lectin-based diagnostic system using circulating antibodies to detect cervical intraepithelial neoplasia and cervical cancer

In the present study, we developed serological strategies using immunoglobulin fractions obtained by protein A chromatography to screen for cervical cancer and cervical intraepithelial neoplasia I (CIN I). The reactivities of the immunoglobulins purified from sera of women with normal cytology, CIN I and cervical cancer were compared in enzyme-linked immunosorbent assays (ELISA) and enzyme-linked lectin assays (ELLAs). To capture the immunoglobulins, ELISAs and ELLAs were performed in protein A immobilized microplates. The reactivity of immunoglobulin in ELISA was in the increasing order normal cytology, CIN I and cervical cancer, while that in ELLAs for detecting fucosylation was in the decreasing order normal cytology, CIN I and cervical cancer. It was confirmed that women with CIN I were distinguishable from women with normal cytology or women with cervical cancer in the ELISA or the ELLA for detecting fucosylation with considerable sensitivity and specificity. Women with cervical cancer were also distinguishable from women with normal cytology with high sensitivity (ELISA: 97%, ELLA: 87%) and specificity (ELISA: 69%, ELLA: 72%). Moreover, the logistic regression model of the ELISA and the ELLA discriminated cervical cancer from normal cytology with 93% sensitivity and 93% specificity. These results indicate that the ELISAs and the ELLAs have great potential as strategies for primary screening of cervical cancer and CIN. It is expected that the ELISA and the ELLA can provide new insights to understand systemic changes of serum immunoglobulins during cervical cancer progression.

Triage of high-risk human papillomavirus-positive women by methylated POU4F3

BACKGROUND

Insufficient specificity of the high-risk human papillomavirus (hrHPV) assay in primary cervical cancer screening results in unnecessary referral. Additional assays to triage hrHPV-positive women are needed to improve molecular cervical cancer screening. DNA methylation is a promising biomarker in cervical cancer. We evaluated the clinical performance of potentially methylated genes as a triage assay for hrHPV-positive women.

RESULTS

We conducted a retrospective hospital-based case-control study in Taiwan. Cervical scrapings were collected before colposcopy for hrHPV testing and quantitative methylation-specific PCR (QMSP) of 16 genes. Five genes, POU4F3, HS3ST2, AJAP1, PAX1, and SOX1, were prioritized for the clinical performance to triage hrHPV-positive women. Two hundred cervical scrapings were randomly classified into a training set (n = 111) and testing set (n = 89). All samples were tested for hrHPV using a Hybrid Capture II (HCII) assay. HrHPV-positive women were subjected to DNA methylation analysis by QMSP. In the training set, the receiver operating characteristic (ROC) curves defined the optimal methylation index (M-index) cutoff values for discriminating CIN3(+) from CIN1/normal, which then were applied to the testing set. Among the five genes, POU4F3 revealed the highest area under the ROC curve (AUC) (0.86; 95 % CI, 0.78-0.95) in detecting CIN3(+). In the testing set, POU4F3 revealed the best clinical performance in triage of hrHPV-positive women with a sensitivity of 74 % and specificity of 89 % for detecting CIN3(+).

CONCLUSIONS

POU4F3 methylation analysis is a potential molecular tool for triage in detecting CIN3(+) in hrHPV-positive women. The combined use of broad-spectrum HPV assay and POU4F3 methylation analysis as a new generation of molecular cervical cancer screening warrants further population-based study.

The significantly lower risk of cervical cancer at and after the recommended age to begin and end screening compared to breast and colorectal cancer

OBJECTIVE

We compare risk of cervical, colorectal, and breast cancer (and two pre-cancers: cervical intraepithelial neoplasia (CIN) grade 2-3 and colorectal adenomas) at and after the recommended ages to begin and end screening in the United States.

METHODS

Surveillance, Epidemiology, and End Results data were used with Monte Carlo simulations to estimate risk at and after the ages to screen.

RESULTS

At the age to begin screening, absolute risk of breast and colorectal cancer was 381 and 53 times higher, respectively, than cervical cancer (0.0122, 95% CI: 0.0089-0.0162 and 0.0017, 95% CI: 0.0012-0.0023 vs. 3.2e(-5), 95% CI: 2.3e(-5)-4.3e(-5)). Risk of colorectal adenomas and breast cancer was 45 and 2.4 times higher than CIN 2-3 (0.2319, 95% CI: 0.1287-0.3624 and 0.0122, 95% CI: 0.0089-0.0017 vs. 0.0051, 95% CI: 0.0029-0.0081). After the age to end screening, breast and colorectal cancer risk was 17 and 11 times higher, respectively, than cervical cancer.

CONCLUSIONS

Risk of cervical cancer at and after the recommended ages for screening is significantly lower than that of breast and colorectal cancer. Differences may become more pronounced in the era of HPV vaccines. Comparison of risk between cancers provides a novel perspective to inform future guideline development.

Cancer prevention: state of the art and future prospects

Cancer imposes a heavy societal burden worldwide, in terms of both epidemiology and costs. The introduction of more sophisticated imaging and diagnostic techniques and advanced drugs that specifically target tumor cells is leading to increasingly expensive treatments, which may be affordable only for few patients. Prevention, and particularly primary prevention, is an effective way of addressing the challenging issue of cancer, since between a third and a half of cancers could be prevented on the basis of our current knowledge of risk factors. Moreover, prevention is cost-effective, its effects are not limited to high-risk subjects but extend to the entire population, and it is not dependent on socioeconomic status. Regulatory measures can have a broad impact, even on future generations; by empowering and educating subjects, promoting healthy behaviours and teaching self-care, they can trigger a virtuous cycle. In recent decades, oncology has shifted from being merely reactive to being proactive; this shift has led to the development of so-called "P4 medicine", where the 4 Ps stand for "preventive", "predictive", "personalized" and "participatory". Prevention programs are an important part of the effort to control cancer, as they are able to reduce both the incidence of cancer and mortality. For instance, screening for colorectal, breast and cervical cancer is reducing the burden of these common tumors. Anti-cancer vaccines, both prophylactic and therapeutic, constitute another important preventive tool. Although progress has been made in these areas, much remains to be done. With regard to screening programs, coverage could be increased by introducing new, more acceptable, less invasive tests, stratifying screening through correlation with anamnestic, clinical, radiological and genomic data (so-called "populationbased personalized cancer screening"), and exploiting new information and communication technologies, such as smartphone applications or personalized text messages (so-called "screening 2.0"). Advocacy and recommendations by physicians can also play a role, in that eligible subjects need to be able to discuss their doubts and their perceived psycho-social barriers. However, new screening initiatives should be implemented only after a careful health technology assessment has been performed within the framework of evidence-based medicine, organized screening programs have been strengthened and opportunistic or spontaneous programs have been limited.

HPV Testing from Dried Urine Spots as a Tool for Cervical Cancer Screening in Low-Income Countries

Nowadays, several screening strategies are available to prevent cervical cancer, but inadequate resources, sociocultural barriers, and sampling issues impede their success in low-income countries. To overcome these issues, this study aimed to evaluate the performance of human papillomavirus (HPV) testing from dried urine spots (DUS). Eighty-eight urine samples (including 56 HPV DNA positive specimens) were spotted on filter paper, dried, and stored in paper-bags. HPV DNA was detected from the DUS after 1 week and 4 weeks of storage using a polymerase chain reaction (PCR) assay. The sensitivity, specificity, and concordance of the DUS-based HPV test were evaluated by comparing the results with those of HPV testing on fresh urine samples as the gold standard. The sensitivity of the test was 98.21% (95% CI: 90.56–99.68) for DUS stored for 1 week and 96.42% (95% CI: 87.88–99.01) for DUS stored for 4 weeks. The specificity was 100% (95% CI: 89.28–100) at both time points. The concordance between DUS and fresh urine HPV testing was “almost perfect” using the κ statistic. These preliminary data suggest that a DUS-based assay could bypass sociocultural barriers and sampling issues and therefore could be a suitable, effective tool for epidemiological surveillance and screening programs, especially in low-income countries.

Human papillomavirus (HPV) types 16 and 18 in liquid-based cervical cytology samples

Human papillomavirus (HPV) DNA testing is replacing cervical cytology as a primary cervical cancer screening tool. The aim of this study was to determine the frequency of occurrence of HPV types 16 and 18 in liquid-based cytology (LBC) cervical samples in our set-up. This study comprised of 302 LBC cervical samples. HPV 16 and HPV 18 were detected by polymerase chain reaction (PCR), and the results were compared between normal (n = 155), inflammatory (n = 99), squamous (n = 37) and glandular abnormalities (n = 11). Of our patient cohort, 73.8 % was ≤40 years old. We found HPV 16 DNA in 91/302 (30.1 %) cases and HPV 18 DNA in 21/302 (6.95 %). HPV types 16 and 18 were detected in 25.8 and 4.5 % cytologically normal samples, respectively. HPV 16 was positive in 29.3 % of inflammatory samples. Squamous cervical abnormalities were more often HPV positive (HPV 16 in 48.6 %; HPV 18 in 29.7 %) than glandular abnormalities (36.4 and 18.2 %, respectively). We found high-risk HPV DNA in more than one third of the tested women. A good number of these HPV-positive cases were negative in cervical cytology.

Human papillomavirus vaccines: key factors in planning cost-effective vaccination programs

Prophylactic HPV vaccines hold tremendous potential for reducing cervical and non-cervical HPV-related disease burden worldwide. To maximize on this potential, policy officials will need to carefully consider available evidence, existing uncertainties and the cost-effectiveness of mass HPV vaccination programs in the context of their respective nations and/or regions. Proper harmonization of primary prevention strategies with secondary prevention efforts will also be important. Decisions following such considerations may ultimately depend on programmatic objectives, infrastructure and available resources. Continued research and surveillance surrounding HPV vaccination will be essential for filling current knowledge gaps, and forcing ongoing reconsiderations of selected immunization strategies.

Lysyl oxidase genetic variants affect gene expression in cervical cancer

Lysyl oxidase (LOX) is a copper-dependent amine oxidase that plays important roles in the homeostasis of tumors. The aim of this study was to investigate the association between LOX polymorphisms and cervical cancer, and the effect of these polymorphisms on gene expression. We evaluated two polymorphisms of LOX, rs1800449G/A (G473A) and rs2278226C/G, in 262 cervical cancer cases and 298 healthy controls in the Chinese population. Results showed that the prevalence of rs1800449AA genotype was significantly increased in cases than in controls (p=0.004). Individuals who carried the rs1800449A allele had a 1.56-fold increased risk for cervical cancer than those with the rs1800449G allele (p=0.003). The rs2278226CG genotype also revealed a significantly higher proportion in cases (20.6%) than in controls (7.7%, p<0.001). Interestingly, when analyzing these two polymorphisms with the serum level of LOX, we identified that cervical cancer patients carrying the rs2278226CG genotype had a significantly elevated level of LOX than those with rs2278226CC wild type, whereas the same phenomenon was not observed in controls. The rs1800449 polymorphism did not affect the LOX serum level in either controls or patients. These results suggest that the polymorphisms in the LOX gene may be involved in the development of cervical cancer through various mechanisms.