Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices

Are we ready for self-sampling for cervical cancer screening? Insights from service providers and policy makers in Nepal

Cervical cancer is the leading cancer among women in Nepal, but the country has very low screening rate, with only 8.2% of women being screened. In recent years, a self-sampling kit for testing for the human papillomavirus (HPV) has been developed to allow self-sampling and enable early detection of cervical abnormalities. This kit enables women to collect cervical samples without the need for trained healthcare providers or healthcare facilities. Nevertheless, there has been a notable absence of scientific studies to analyse the feasibility and acceptability of self-sampling for cervical cancer screening in Nepal, particularly from the perspective of various service providers. The qualitative research method used semi-structured in-depth interviews and key informant interviews with healthcare providers, online service providers, and policymakers. These interviews were conducted in person with 20 participants until data saturation was achieved. Thematic analysis was performed where the translated data was coded inductively using NVivo 12. The majority of the participants identified the self-sampling method as an alternative sampling option for detection of cervical abnormalities/cancer in Nepal. Barriers to self-sampling included a low level of knowledge and information, the cost of the self-sampling kit, unclear information regarding self-sampling process and concerns about inaccurate results among women and girls, who are the end users. Similarly, factors such as knowledge and information regarding the self-sampling technique, accessibility of available services and information, and national self-care guidelines and policies for cervical cancer screening were identified as facilitators for self-sampling. It is crucial to have evidence-based discussions, especially regarding the effectiveness of a self-care approach in cervical cancer screening and help create a supportive policy environment for implementing self-care strategies in Nepal. Furthermore, disseminating education and information nationwide through campaigns to raise awareness about self-sampling is essential among beneficiaries for the scaling up of self-sampling for cervical cancer in Nepal.

Biological functions of extracellular vesicle double C2-like domain beta in cervical cancer

Double C-2 Like Domain Beta (DOC2B) located at 17q13.3 prevents metastasis by senescence induction and epithelial to mesenchymal transition inhibition in cervical cancer (CC). The extracellular vesicle (EV) mediated trafficking of DOC2B and its impact on tumor suppressive activity are not investigated in CC. Using a retroviral method, we first ectopically expressed DOC2B in SiHa, which do not normally express DOC2B. DOC2B-SiHa and vector-SiHa EVs were co-incubated separately with recipient cell and subjected to various cellular and biochemical experiments. For the first time, we demonstrated that DOC2B localizes to EVs, and its transfer to EV may require intracellular calcium. Co-culture of SiHa and HeLa cells with DOC2B-SiHa derived EVs induced morphological changes and suppressed their growth and migration, possibly by induction of G0/G1 to S phase arrest and anoikis. DOC2B-SiHa EVs elevated intracellular reactive oxygen species (ROS) and calcium levels and promoted lipid droplet accumulation and lipid peroxidation rate in recipient cells. DOC2B-SiHa EVs reduced active AKT1 and ERK1/2 levels and EMT marker expression and enhanced cellular senescence and cytotoxic effects of cisplatin. Re-expression of DOC2B significantly altered the global metabolite profile of EVs.  Finally, we demonstrated that intracellular calcium chelation significantly reduces DOC2B localization to EVs and impacts its tumor-suppressive properties. Altogether, EV-mediated DOC2B transfer may reduce the aggressive behavior of CC cells.

Integration and acceptability of cervical cancer screening as part of postnatal care among women attending postnatal clinics in the Accra Metropolis, Greater Accra Region, Ghana

Cervical cancer is a recognized preventable disease yet the fourth most common cancer among women globally. This study assessed the integration and acceptability of cervical cancer screening as part of routine sixth-week postnatal care among women attending a postnatal clinic. This was a cross-sectional descriptive study among 347 postpartum women who were attending their 6th-week postnatal visit. A Pap smear test was performed on each consenting study participant. Only conventional cervical smears were performed. The Pap smear samples were taken using a special kit (PAP-PAK Cytology brush kit) for a 3-smear sampling of the ectocervix (emphasis on the squamo-columnar junction), endocervix (endocervical canal past squamo-columnar junction) and the posterior fornix via a cervical-vaginal scraper and a CytoSoft cytology brush respectively. All smears were fixed with 95% ethyl alcohol and allowed to dry in cool air. The samples were sent to the cytology laboratory and stained with the Pap staining technique. All the smears were examined and reported by the cytology department of Korle-Bu Teaching Hospital. Descriptive statistics such as frequency tables were drawn and proportions were estimated. Bivariable analysis between categorical variables and outcome variables was done. A p-value ≤ 0.05 was considered statistically significant. Most (90.5%) of the study participants were satisfied with the Pap test procedure and about 52.7% indicated that paying Gh₵60.00 ($12.50) for screening test was affordable. The outcome of Pap smear tests revealed that most (90.8%) of the participants had normal Pap test results. In the univariable analysis, participants' educational level (p = 0.006); occupation (p < 0.001), and contraceptive use (p = 0.019) were significantly associated with the acceptability of the Pap test procedure. The multivariable analysis revealed that educational level (aOR = 3.27; 95% CI = 1.05-10.21; p = 0.041) and occupation (aOR = 6.49; 95% CI = 1.67-25.29; p = 0.007) were significantly associated with the acceptability of the Pap test procedure and showed higher odds of acceptability. Integration of cervical cancer screening into the routine sixth-week postnatal clinic has the potential to be feasible with anticipated high uptake. We therefore recommend a pilot study be initiated to integrate cervical cancer screening into the routine maternal health services as part of postnatal care. Also, the Ministry of Health/Ghana Health Service should initiate discussion with the National Health Insurance Authority for possible inclusion as part of the national health insurance scheme's benefit package in the nearby future.

Poor Performance of Applicator Tampon-Based Self-Collection for Liquid-Based Cytology Among Women Attending a Tertiary Hospital in South Africa

BACKGROUND

The South African Cervical Cancer Prevention and Control Policy was updated in June 2017, recommending liquid-based cytology (LBC) as the preferred screening method and the investigation of self-sampling for cervical cancer screening.

AIM

To compare the performance of the Self Collection Cervical Health Screening Kit [SelfCerv (applicator tampon)] to the Cervex-Brush Combi for cytology screening. The study further aimed to compare high-risk (hr-) human papillomavirus (HPV) and LBC test results from both methods.

METHODS

The study included 446 paired samples, comprising self-collected (SelfCerv) and healthcare provider-collected (Cervex-Brush Combi) samples from women aged ≥ 18 years attending gynaecology outpatient clinics at a tertiary hospital in Pretoria, South Africa. LBC slides were prepared using the ThinPrep 5000 processor and manually stained with Hematoxylin and Eosin (H&E). Detection of 14 hr-HPV types was performed using the Abbott RealTime HR-HPV assay. Statistical analyses were performed using STATA version 17.0 (Stata Corp., College Station, Texas, USA).

RESULTS

A statistically significant difference in cervical cytology detection between the two methods was observed (p = 0.0025). The Cervex-Brush Combi was more effective in collecting endocervical cells (73.4%; 95% CI: 69.0-77.9) compared to the SelfCerv applicator tampon (7.3%; 95% CI: 4.7-9.9); (p < 0.001). Cytological abnormalities were detected in 65.4% (136/208) of participants who tested positive for hr-HPV by healthcare provider sampling compared to 40.8% (84/206) by self-sampling. A fair agreement (κ: 0.35) with a concordance rate of 96.2% (95% CI: 94.4-98.0) was observed for specimen adequacy and diagnosis parameters [κ: 0.34, with a concordance rate of 67.7% (95% CI: 63.2-72.1)] between the two methods.

CONCLUSION

The findings of this study do not support the implementation of applicator tampon-based self-collection as a method for cytology-based cervical cancer screening.

High-risk human papillomavirus testing for cervical cancer screening in Uganda: Considering potential harms and benefits in a low-resource setting

OBJECTIVES

The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.

METHODS

A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.

RESULTS

Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.

DISCUSSION

For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.

Early adoption of innovation in HPV prevention strategies: closing the gap in cervical cancer

Cervical cancer (CC) is one of the highest prevailing causes of female cancer-related mortality globally. A significant discrepancy in incidence has been noted between high and low-middle-income countries. The origins of CC have been accredited to the human papillomavirus (HPV) with serotypes 16 and 18 being the most prevalent. HPV vaccines, with 90%-97% efficacy, have proven safe and currently function as the primary prevention method. In addition, secondary prevention by timely screening can potentially increase the 5-year survival rate by >90%. High-precision HPV DNA testing has proven to be both highly sensitive and specific for early detection and is advocated by the WHO. Lack of public awareness, poor screening infrastructure and access to vaccines, socio-cultural concerns, along with economic, workforce-associated barriers and the presence of marginalised communities unable to access services have contributed to a continued high incidence. This article comprehensively analyses the efficacy, coverage, benefits and cost-effectiveness of CC vaccines and screening strategies including the transition from cytological screening to HPV self-sampling, while simultaneously exploring the real-world disparities in their feasibility. Furthermore, it calls for the implementation of population-based approaches that address the obstacles faced in approaching the WHO 2030 targets for CC elimination.

Usability of a smartphone-compatible, confocal micro-endoscope for cervical cancer screening in resource-limited settings

BACKGROUND

More efficient methods to detect and treat precancerous lesions of the cervix at a single visit, such as low-cost confocal microscopy, could improve early diagnosis and hence outcomes. We piloted a prototype smartphone-compatible confocal micro-endoscope (SCME) among women presenting to a public cervical cancer screening clinic in Kampala, Uganda. We describe the piloting of the SCME device at an urban clinic used by lower cadre staff.

METHODS

We screened women aged 18 and 60 years, who presented for cervical cancer screening at the Kawempe National Referral Hospital Kampala, and evaluated the experience of their providers (nurses). Nurses received a 2-day training by the study doctors on how to use the SCME, which was added to the standard Visual Inspection with Acetic acid (VIA)-based cervical cancer screening. The SCME was used to take colposcopy images before and after VIA at positions 12 and 6 O'clock if VIA negative, and on precancer-suspicious lesions if VIA positive. We used questionnaires to assess the women's experiences after screening, and the experience of the nurses who operated the SCME.

RESULTS

Between November 2021 and July 2022, we screened 291 women with a median age of 36 years and 65.7% were HIV positive. Of the women screened, 146 were eligible for VIA, 123 were screened with the SCME, and we obtained confocal images from 103 women. Of those screened with the SCME, 60% found it comfortable and 81% were willing to screen again with it. Confocal images from 79% of the women showed distinguishable cellular features, while images from the remaining 21% were challenging to analyze. Nurses reported a mean score of 85% regarding the SCME's usefulness to their work, 71% regarding their satisfaction and willingness to use it again, 63% in terms of ease of use, and 57% concerning the ease of learning how to operate the SCME.

CONCLUSION

Our findings demonstrate the feasibility of using the SCME by lower cadre staff in low-resource settings to aid diagnosis of precancerous lesions. However, more work is needed to make it easier for providers to learn how to operate the SCME and capture high-quality confocal images.

Enhancing outcome prediction of concurrent chemoradiation treatment in patients with locally advanced cervical cancer through plasma extracellular vesicle proteomics

Most patients with locally advanced cervical cancer (LACC) are primarily treated using concurrent chemoradiation (CCRT); however, LACC lacks reliable predictive biomarkers. Extracellular vesicles (EVs) could define the dynamic biological response to CCRT. However, the relationship between EVs and the therapeutic response to LACC is unestablished. Thus, we aimed to determine the relationship of plasma EVs pre- and post-CCRT in 62 patients with LACC. For proteomic analyses, EVs were isolated using ultracentrifugation (UC) with size exclusion chromatography or UC alone. We found that plasma particle concentration was significantly increased post-treatment in non-responders. After CCRT, there was a decrease in proteins related to serine protease and fibrinogen, which contribute to tumor microenvironment alteration. This reduction also extended to proteins involved in innate immune and viral immune responses, correlating with reduced tumor burden. Sparse partial least squares discriminant analysis revealed 8, 13, and 19 proteins at diagnosis, one month, and three months, respectively, influencing the CCRT response. Among these, FIBG, TFR1, HBA, and FINC are prognostic markers according to The Cancer Genome Atlas tissue gene expression database. Our discriminant model demonstrated excellent specificity and negative predictive value, underscoring the model's reliability in determining responsiveness to CCRT and highlighting the potential clinical applicability of EVs in improving outcomes in LACC.

A Systematic Review of Interventions to Promote Cervical Cancer Screening among Immigrant Vietnamese Women

Vietnamese women have a higher incidence rate of cervical cancer and are less likely to have ever been screened for cervical cancer than their White counterparts in the US. This review synthesizes findings from published interventions to promote cervical cancer screening in this vulnerable population. Articles were identified through a systematic search of PsycInfo, Embase, Pubmed, Web of Science, and the Cochrane Register of Controlled Trials in October 2022. Articles were included if they were published in a peer-reviewed journal, written in English, included one or more interventions promoting cervical cancer screening, assessed at least one outcome relevant to screening, and included a sample of ≥ 70% Vietnamese participants. Quality assessment scores were computed using the Downs and Black Checklist. Fifteen articles met review inclusion criteria. Studies were, on average, of good quality. Most studies were conducted in the US (n = 12), used a quasi-experimental design (n = 9), and employed multiple intervention strategies (n = 12). Intervention strategies included educational sessions, lay health worker (LHW) outreach, small media, mass media, patient navigation, and community or healthcare-based strategies. The most common study outcomes were screening intention and receipt. All but two studies reported improved cervical cancer screening outcomes following intervention. Findings support the effectiveness of multicomponent culturally tailored interventions to improve cervical cancer screening outcomes in immigrant Vietnamese women. Further research is needed to determine whether these interventions will be as successful in non-US countries and to address broader community- and healthcare-based factors in screening.

Drivers of breast cancer and cervical cancer screening among women of reproductive age: insights from the Ghana Demographic and Health Survey

BACKGROUND

The two major causes of cancer-related deaths among women in Ghana are breast cancer (BC) and cervical cancer (CC). These types of cancers typically do not show any symptoms until they have progressed. Therefore, it is important to screen for early detection. This research aimed to investigate the rate of breast cancer and cervical cancer screening, as well as the factors associated with it, among women of reproductive age in Ghana.

METHODS

This study analysed data from the 2022 Ghana Demographic and Health Survey. A total of 15,014 women aged 15 to 49 years were included in the analysis. Descriptive statistics and binary logistic regression were employed to analyse the data with the aid of STATA/SE, version 17.

RESULTS

It was found that 18.4% and 5.0% of the women had screened for BC and CC, respectively. Women aged 45-49 years were about three times more likely (aOR = 2.83, 95% CI: 1.88-4.24) to screen for BC compared to those aged 15-19 years. Women who had tested for HIV had increased odds (aOR = 1.88, 95% CI: 1.56-2.25) of screening for BC compared to their counterparts. Women within the richest wealth index (aOR = 1.95, 95% CI: 1.40-2.72) had increased odds of screening for BC compared to those in the poorest wealth index. Regarding CC screening, women with higher education (aOR = 2.56, 95% CI: 1.53-4.29) were two times more likely to screen for CC compared to those with no formal education. Women who did not use tobacco (aOR = 0.45, 95% CI: 0.21-0.96) had decreased odds of CC screening compared to their counterparts.

CONCLUSIONS

This study showed that the uptake of BC and CC screening services among women in Ghana was very low. The drivers of BC and CC screening included enabling, predisposing, and need factors. Stakeholders can leverage the mass media to raise awareness and educate women in reproductive age about the importance of BC and CC screening. This study provides relevant information that can inform BC and CC policies and programmes in Ghana.

Knowledge, Attitude and Practice Concerning Cervical Cancer Screening Among Reproductive Age Group Women in Low-Resource Settings Yenagoa Bayelsa State

Background

Nigeria has one of the highest rates of cervical cancer morbidity and mortality in Sub-Saharan Africa. Both the human papillomavirus vaccine (HPV) and cervical screening are effective prevention strategies against both HPV infection and cervical cancer. Lack of awareness, limited knowledge, limited decision-making agency, lack of spousal support and stigma are barriers to uptake of these preventive measures. Cervical cancer is the second most diagnosed cancer and the third leading cause of cancer death in women worldwide. Eighty three percent (83%) of the world's new cases and 85% of all cervical cancer-related deaths occur in developing countries. It is primarily caused by human papilloma virus (HPV); a sexually transmitted pathogen that could be prevented with safe sexual practice and using vaccines, among others. The aim of the study was to assess the knowledge and attitude of reproductive age group women in low resource setting in towards cervical cancer and its prevention in Yenagoa, Bayelsa State Nigeria.

Methodology

This study employed the use of a descriptive study design to examine the knowledge and assessment of cervical cancer among women of reproductive age (19-54), about cervical cancer, its prevention, and their utilization of Pap smear screening; using a convenience sample of 406 women in two communities (Okaka and Agudama) in Yenagoa Local Government Area of Bayelsa State, Nigeria. Women voluntarily completed a structured questionnaire.

Result

Results showed that women who participated in the study were aware of cervical cancer (78.3%; n=318) but many (70.4%; n= 286) were unaware of Pap smears as the screening tests for cervical cancer. Although few of them (45.6%; n =185) knew about a screening center, out of which 17.6% (n= 32) reported that the screening center was less than 2km away from their residences.

Conclusion

There is need for health care professionals, to intensify efforts to increase awareness about cervical cancer screening and encourage women through the different clinics to use these services. The benefits of screening and early diagnosis of cervical cancer should be emphasized to enhance the utilization of cervical cancer screening services.

Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination

Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.

A Multimodality Treatment Approach for the Management of Recurrent Cervical Cancer in an Elderly Female Patient: A Case Report

Squamous cells in the cervix can develop into a type of cervical cancer. Cervical squamous cells are the cells that line the outside of the cervix. These thin, flat cells have a striking resemblance to fish scales under a microscope. Squamous cell carcinomas (SCCs) are the most common type of cervical cancer. We report the case of a 60-year-old woman with SCC devoid of a family history of cancer or related diseases. Following a biopsy confirming SCC, the patient's contrast-enhanced computed tomography scan revealed a somewhat enlarged cervix along with a white discharge per vagina. The patient underwent a Wertheim hysterectomy and was diagnosed with microinvasive SCC, adenomyosis, and negative lymph nodes. Two years after being free from disease, the issue reappeared even with routine follow-ups. The patient underwent six rounds of chemotherapy, followed by chemoradiation and interstitial brachytherapy. The multimodality therapy method applied to an aged female patient experiencing recurrent SCC of the cervix is demonstrated in this case study. It underlines how crucial regular follow-ups and multimodal therapy are to control recurrent cervical cancer.

Discovery and technical validation of high-performance methylated DNA markers for the detection of cervical lesions at risk of malignant progression in low- and middle-income countries

BACKGROUND

Cervical cancer remains a leading cause of death, particularly in developing countries. WHO screening guidelines recommend human papilloma virus (HPV) detection as a means to identify women at risk of developing cervical cancer. While HPV testing identifies those at risk, it does not specifically distinguish individuals with neoplasia. We investigated whether a quantitative molecular test that measures methylated DNA markers could identify high-risk lesions in the cervix with accuracy.

RESULTS

Marker discovery was performed in TCGA-CESC Infinium Methylation 450 K Array database and verified in three other public datasets. The panel was technically validated using Quantitative Multiplex-Methylation-Specific PCR in tissue sections (N = 252) and cervical smears (N = 244) from the USA, South Africa, and Vietnam. The gene panel consisted of FMN2, EDNRB, ZNF671, TBXT, and MOS. Cervical tissue samples from all three countries showed highly significant differential methylation in squamous cell carcinoma (SCC) with a sensitivity of 100% [95% CI 74.12-100.00], and specificity of 91% [95% CI 62.26-99.53] to 96% [95% CI 79.01-99.78], and receiver operating characteristic area under the curve (ROC AUC) = 1.000 [95% CI 1.00-1.00] compared to benign cervical tissue, and cervical intraepithelial neoplasia 2/3 with sensitivity of 55% [95% CI 37.77-70.84] to 89% [95% CI 67.20-98.03], specificity of 93% [95% CI 84.07-97.38] to 96% [95% CI 79.01-99.78], and a ROC AUC ranging from 0.793 [95% CI 0.68-0.89] to 0.99 [95% CI 0.97-1.00] compared to CIN1. In cervical smears, the marker panel detected SCC with a sensitivity of 87% [95% CI 77.45-92.69], specificity 95% [95% CI 88.64-98.18], and ROC AUC = 0.925 [95% CI 0.878-0.974] compared to normal, and high-grade squamous intraepithelial lesion (HSIL) at a sensitivity of 70% (95% CI 58.11-80.44), specificity of 94% (95% CI 88.30-97.40), and ROC AUC = 0.884 (95% CI 0.822-0.945) compared to low-grade intraepithelial lesion (LSIL)/normal in an analysis of pooled data from the three countries. Similar to HPV-positive, HPV-negative cervical carcinomas were frequently hypermethylated for these markers.

CONCLUSIONS

This 5-marker panel detected SCC and HSIL in cervical smears with a high level of sensitivity and specificity. Molecular tests with the ability to rapidly detect high-risk HSIL will lead to timely treatment for those in need and prevent unnecessary procedures in women with low-risk lesions throughout the world. Validation of these markers in prospectively collected cervical smear cells followed by the development of a hypermethylated marker-based cervical cancer detection test is warranted.

Vaginal Microbiota and HPV in Latin America: A Narrative Review

With the expansion of human microbiome studies in the last 15 years, we have realized the immense implications of microbes in human health. The human holobiont is now accepted, given the commensal relationships with bacteria, fungi, parasites, viruses, and human cells. The cervicovaginal microbiota is a specific case within the human microbiome where diversity is lower to maintain a chemical barrier of protection against infections. This narrative review focuses on the vaginal microbiome. It summarizes key findings on how native bacteria protect women from disease or predispose them to damaging inflammatory processes with an emphasis on the role of HPV infections in Latin America, one of the world's regions with the highest cervical cancer prevalence.

Comparison of Colposcopy and Histopathology in Abnormal Cervix

Cervicovaginal cancer (CVC) is the most common malignancy of the genital tract. Colposcopy is a diagnostic procedure that is used to examine the cervix and tissue samples of the urethra and vulva in a magnified view. The colposcopy and histological findings of unhealthy cervixes in a tertiary care hospital were compared. This comparative cross-sectional study was conducted from November 2022 to March 2023 among women with a variety of gynecological complaints who visited the Department of Obstetricians and Gynecologists in a tertiary care facility. One hundred participants were included in this study. The data collected were analyzed using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States). Participants had an average age of 35.22 ± 7.18 years, and white discharge was the most reported ailment (73%). Comparing the results of the colposcopy with the histological findings revealed a sensitivity of 91.5% and a specificity of 72.2%. The high sensitivity of colposcopy highlights the need to combine it with histological techniques to obtain better results.

Precision Population Cancer Medicine in Cancer of the Uterine Cervix: A Potential Roadmap to Eradicate Cervical Cancer

With the success of the Human Genome Project, the era of genomic medicine (GM) was born. Later on, as GM made progress, there was a feeling of exhilaration that GM could help resolve many disease processes. It also led to the conviction that personalized medicine was possible, and a relatively synonymous word, precision medicine (PM), was coined. However, the influence of environmental factors and social determinants of diseases was only partially given their due importance in the definition of PM, although more recently, this has been recognized. With the rapid advances in GM, big data, data mining, wearable devices for health monitoring, telemedicine, etc., PM can be more easily extended to population-level health care in disease management, prevention, early screening, and so on.and the term precision population medicine (PPM) more aptly describes it. PPM's potential in cancer care was posited earlier,and the current authors planned a series of cancer disease-specific follow-up articles. These papers are mainly aimed at helping emerging students in health sciences (medicine, pharmacy, nursing, dentistry, public health, population health), healthcare management (health-focused business administration, nonprofit administration, public institutional administration, etc.), and policy-making (e.g., political science), although not exclusively. This first disease-specific report focuses on the cancer of the uterine cervix (CC). It describes how recent breakthroughs can be leveraged as force multipliers to improve outcomes in CC - by improving early detection, better screening for CC, potential GM-based interventions during the stage of persistent Human papillomavirus (HPV) infection and treatment interventions - especially among the disadvantaged and resource-scarce populations. This work is a tiny step in our attempts to improve outcomes in CC and ultimately eradicate CC from the face of the earth.

Validation in Zambia of a cervical screening strategy including HPV genotyping and artificial intelligence (AI)-based automated visual evaluation

BACKGROUND

WHO has recommended HPV testing for cervical screening where it is practical and affordable. If used, it is important to both clarify and implement the clinical management of positive results. We estimated the performance in Lusaka, Zambia of a novel screening/triage approach combining HPV typing with visual assessment assisted by a deep-learning approach called automated visual evaluation (AVE).

METHODS

In this well-established cervical cancer screening program nested inside public sector primary care health facilities, experienced nurses examined women with high-quality digital cameras; the magnified illuminated images permit inspection of the surface morphology of the cervix and expert telemedicine quality assurance. Emphasizing sensitive criteria to avoid missing precancer/cancer, ~ 25% of women screen positive, reflecting partly the high HIV prevalence. Visual screen-positive women are treated in the same visit by trained nurses using either ablation (~ 60%) or LLETZ excision, or referred for LLETZ or more extensive surgery as needed. We added research elements (which did not influence clinical care) including collection of HPV specimens for testing and typing with BD Onclarity™ with a five channel output (HPV16, HPV18/45, HPV31/33/52/58, HPV35/39/51/56/59/66/68, human DNA control), and collection of triplicate cervical images with a Samsung Galaxy J8 smartphone camera™ that were analyzed using AVE, an AI-based algorithm pre-trained on a large NCI cervical image archive. The four HPV groups and three AVE classes were crossed to create a 12-level risk scale, ranking participants in order of predicted risk of precancer. We evaluated the risk scale and assessed how well it predicted the observed diagnosis of precancer/cancer.

RESULTS

HPV type, AVE classification, and the 12-level risk scale all were strongly associated with degree of histologic outcome. The AVE classification showed good reproducibility between replicates, and added finer predictive accuracy to each HPV type group. Women living with HIV had higher prevalence of precancer/cancer; the HPV-AVE risk categories strongly predicted diagnostic findings in these women as well.

CONCLUSIONS

These results support the theoretical efficacy of HPV-AVE-based risk estimation for cervical screening. If HPV testing can be made affordable, cost-effective and point of care, this risk-based approach could be one management option for HPV-positive women.