Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand

AIMS

Cervical cancer remains a burden within Aotearoa New Zealand, with 2022 screening rates sitting 12.7% below target. The National Cervical Screening Programme has changed to primary human papillomavirus (HPV) testing for all screen-eligible people, with the aim for home self-testing. Little is known about the readiness of primary care for the change to self-testing and its associated challenges. A pilot HPV cervical cancer screening programme is being conducted in 17 practice centres. The aim of this study is to explore smear-taker knowledge at these centres about the use of primary HPV testing for cervical cancer screening.

METHODS

This is an ethically approved questionnaire study, with data from a structured web-based questionnaire sent to all smear-takers at the pilot centres.

RESULTS

We achieved a total completion rate of 57.8%. The average score for "Knowledge of HPV" was 56.5% (range=20-100%). The challenges to patient home HPV self-testing were felt to be overall "not at all" to "mildly challenging". Up to 73.3% of participants identified ongoing needs for further education.

CONCLUSIONS

The findings indicate knowledge deficits regarding HPV testing for cervical cancer screening and a desire for the provision of further education. Overall, respondents felt that no major barriers to implementing HPV self-testing would occur.

The High-Risk Human Papillomavirus Type Influences the Tissue Microenvironment in Cervical Intraepithelial Neoplasia Grade 2

High-risk, cancer-causing human papillomavirus (HPV) types are associated with cervical precancer and cancer. A high proportion of high-risk HPV precancer lesions undergo immune-mediated regression. The purpose of this study was to determine if the tissue microenvironment of HPV16 and 18 (HPV16/18) cervical intraepithelial neoplasia grade 2 lesions differed from other high-risk types (HPV 'other'). Consistent with other studies, we found that progression to higher-grade disease was more frequent in HPV16/18 lesions when compared with HPV 'other' lesions. HPV16/18 lesions were significantly more likely to be indoleamine 2,3,-dioxygenase 1 (IDO1)-positive and were associated with reduced CD8 and FoxP3 T cells in the lesion. In the stroma, reduced Tbet- and CD32-positive cells and increased Blimp1-positive cells were significantly associated with HPV16/18 lesions when compared with HPV 'other' types. On analysis of the IDO1-positive tissues, lesional IDO1 was associated with significantly decreased numbers of CD4-, CD8-, and FoxP3-positive cells in the stroma compared with IDO1-negative tissues. These data suggest that IDO1 expression may impair infiltration of CD4, CD8, and FoxP3 cells into the stroma beneath the precancer lesion. Increased expression of IDO1 may contribute to immune avoidance and an increased frequency of disease progression in HPV16- and 18-positive lesions.

Patient choice may improve adherence to follow-up in cervical screening: a randomised-control trial

AIMS

We investigated whether patient choice of follow-up type improves health-related quality of life (HrQOL) and follow-up attendance in women who have undergone large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 to 3 (CIN 2-3).

METHODS

A three-armed randomised controlled trial including women with newly diagnosed CIN 2-3 post-LLETZ treatment was performed. Consenting women were randomised (1:1:1) to either: (a) colposcopy review at the hospital, (b) follow-up with high-risk human papilloma virus (HrHPV) and smear test in the community or (c) a choice of the aforementioned follow-up options, six months post-treatment. HrQOL was measured and participants were surveyed at baseline and six months regarding preferences for follow-up.

RESULTS

Sixty-eight participants were randomised to follow-up (a), 67 to follow-up (b) and 65 to follow-up (c) (n=200). At six months post-treatment, 47% of patients indicated a preference for (a), 24% for (b) and 26% for (c). We found no significant difference in HrQOL between the study arms. Attendance was greater among patients who chose their follow-up (95.5% vs 91.1%, p=0.06).

CONCLUSION

Choice of follow-up was associated with greater attendance. However, larger studies examining the effects of HrQOL and attendance to different follow-ups are warranted.

An innovative General Practice based Pharmacy Longitudinal Clerkship: using theory to characterise its development, implementation and initial evaluation

BACKGROUND

Longitudinal Integrated Clerkships exist in undergraduate medicine courses. A pilot Pharmacy Longitudinal Clerkship (pPLC) was funded to investigate delivery of this model of clinical education for student pharmacists.

OBJECTIVE(S)

To investigate the development, implementation and initial evaluation of a pPLC.

METHODS

The 11-week pPLC was delivered to two students in two GP practices in Scotland. Mixed theory-based methods were used to gather information on the pPLC structures and processes required and qualitative semi-structured Theoretical Domains Framework (TDF) based interviews explored outcomes with key stakeholders. Informed written consent was obtained. Interviews were audio-recorded, transcribed verbatim and analysed thematically. University Ethics approval was granted.

RESULTS

Data were generated on resources and processes required for a pPLC including funds budgeted for and actually spent on staffing, student travel/subsistence and student clinical 'Kit Bags', learning outcomes, curriculum and training timetable, GP Practice/University contracts. Interviews were completed with the two students, three linked GP clinical supervisors and two Regional Tutors involved. The seven themes were identified and mapped to seven TDF domains including: increased levels of student confidence, and increased student enthusiasm for a career in pharmacy, need for definition of the role of the Regional Tutor for the PLC and GP positivity towards the expected outcomes of clerkship model versus traditional placements.

CONCLUSION

Findings are limited by the small number of participants and settings, but evaluation was positive and the work garnered information on requirements for resources and processes. This will inform 'roll out' of the PLC.

Trends in the overall survival rates in women with advanced ovarian cancer in a single tertiary centre in New Zealand

BACKGROUND

Survival rates for women diagnosed with ovarian cancer are much poorer than other gynaecological cancers and greatly depend on stage at diagnosis. A recent publication showed that unlike some other developed countries, there has been no improvement in the five-year survival rate for those diagnosed with ovarian cancer in New Zealand.

AIM

To compare the five-year survival rate of women diagnosed with advanced ovarian cancer in a single tertiary hospital during two 36-month time periods 10 years apart.

MATERIALS AND METHODS

An observational retrospective review of patient clinical notes, including all women diagnosed with stage three or four ovarian cancer between 2000 and 2002 (Cohort 1) and 2010-2012 (Cohort 2). Eligible patients were identified through the Regional Gynaecology Oncology database. Clinical notes were reviewed to compare the five-year survival rate between these two time periods and look at changes in patterns of care over time.

RESULTS

Eighty-three women were diagnosed in 2000-2002 and 125 women in 2010-2012. There was no difference in five-year survival between cohorts (21.7% vs 23.2%, P = 0.80). Mean age at diagnosis did not differ between cohorts (62.1 years vs 63.5 years, P = 0.43); however, there were more women with stage four cancer in Cohort 2 (14% vs 30%, P = 0.01). In Cohort 2, more women were treated with neoadjuvant chemotherapy (20% vs 34%, P = 0.04) or chemotherapy only (6% vs 18%, P = 0.01).

CONCLUSION

Five-year overall survival in women diagnosed with advanced ovarian cancer in our centre has not changed over the last 10 years.

Pathological process has a crucial role in sentinel node biopsy for vulvar cancer

OBJECTIVES

To report the interim findings of an audit of the outcomes of sentinel node (SN) biopsy performed as a replacement for groin node dissection in women with early stage vulvar cancer in routine clinical practice in Australia and New Zealand.

METHODS

A prospective multi-center study in 8 participating centers. Eligible patients had squamous cell carcinomas clinically restricted to the vulva <4 cm in diameter. SN procedures and pathological assessment were to be performed in accordance with the methods published by the GROINSS-V collaboration [1].

RESULTS

130 women with apparent early stage vulvar cancer were enrolled. Seventeen women subsequently did not meet the eligibility criteria and were excluded. SNs were identified in 111/113 of the remaining women. Twenty-two women had positive nodes. Sixteen of these women had at least 12 months follow up and 7 (44%) had recurrent disease. Eighty-nine women had only negative nodes. Seventy-four of these women had at least 12 months follow up and 6 (8%) had recurrent disease (including 2 [2.7%] with recurrence in the groin). On subsequent review of the two women with negative SNs who had groin recurrences, it was found that the recommended pathology protocol had not been followed. In both cases, SN metastases were identified following serial sectioning of the nodes.

CONCLUSIONS

SN biopsy is feasible in routine clinical practice. However, undetected metastases in a removed SN may be associated with groin recurrence. To ensure patient safety, strict adherence to the pathology protocol is an essential component in the utilization of the sentinel lymph node technique in vulvar cancer.

Patterns of referral and uptake of BReast CAncer (BRCA) gene testing of eligible women with ovarian cancer in New Zealand

AIMS

To determine the proportion of eligible patients with high-grade serous carcinoma of the ovary, fallopian tube or peritoneum discussed at gynaecological oncology multidisciplinary meetings (MDMs) in New Zealand and subsequently referred for genetic counselling and BRCA pathogenic variant testing.

METHODS

Eligible cases were identified from Auckland, Wellington, Christchurch and Dunedin gynaecologic oncology MDM databases between 1 January 2015 to 31 December 2016. Patients who met the eligibility criteria for genetics referral were identified, and cross-referenced against genetic services databases to ascertain the rates of referrals received, the numbers attending appointments, genetic testing offered and range of results.

RESULTS

During the two-year period, 205 patients were eligible for referral. Of these, 143 (70%) patients were referred for genetic counselling with 128 (90%) of this group recommended for BRCA pathogenic variant testing. Of the 126 who undertook the test, results were available for 120 (95%). Nineteen patients (16%) tested positive for a germline BRCA pathogenic variant.

CONCLUSIONS

The New Zealand rate of referral to genetic counselling for women with high-grade serous cancer, (HGSC), of the ovary, fallopian tube or peritoneum diagnosed between 2015-2016 is encouraging when compared with others internationally. The rate of BRCA positive pathogenic variants is comparable to international data.

Initial observation of CIN2 does not appear to reduce quality of life in women under 25 years of age

BACKGROUND

Although the patient perspective is implicit in the practice of medicine, research evaluating this remains scarce. In a climate where clinicians and policy-makers constantly strive to achieve more patient-centred models of care, this omission warrants attention.

AIM

To assess health-related quality of life (HrQoL) in women under 25 years of age with cervical intra-epithelial neoplasia grade 2 (CIN2) receiving conservative management (colposcopy follow-up, with treatment if necessary) compared with those receiving immediate excisional treatment with large loop excision of the transformation zone (LLETZ).

METHODS

An observational study evaluating HrQoL was conducted at Christchurch Women's Hospital, New Zealand. Women undergoing conservative management for CIN2 were compared with those undergoing immediate excisional treatment in an age-matched sample. The Short Form Health Survey 12 version 2 (SF-12v2) was used to evaluate HrQoL. Secondary outcomes of anxiety and sexual function were also assessed.

RESULTS

One hundred and four women with CIN2 participated in the study. Of these, 63 (60%) received conservative management and 41 (40%) received immediate excisional treatment with LLETZ. We found no significant difference in HrQoL between the groups in a multivariate regression analysis adjusted for parity, smoking and socioeconomic status. There were also no significant differences in sexual function or anxiety.

CONCLUSION

We found no difference in HrQoL by management strategy. Conservative management of CIN2 in women under 25 is unlikely to have an adverse impact on self-reported HrQoL, anxiety or sexual functioning compared with conventional management.

Wrong place at the wrong time: A case of cervical embryonal rhabdomyosarcoma in pregnancy

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First case of NACT in cervical embryonal RMS

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Second case occurring in pregnancy

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Histological review outlining diagnostic difficulties

Adjuvant 5-flurouracil, alpha-interferon and interleukin-2 versus observation in patients at high risk of recurrence after nephrectomy for renal cell carcinoma: results of a phase III randomised European Organisation for Research and Treatment of Cancer (Genito-Urinary Cancers Group)/National Cancer Research Institute trial

BACKGROUND

The purpose of this trial was to compare adjuvant 5-flurouracil, alpha-interferon and interleukin-2 to observation in patients at high risk of recurrence after nephrectomy for renal cell carcinoma (RCC) in terms of disease free survival, overall survival and quality of life (QoL).

PATIENTS AND METHODS

Patients 8weeks post nephrectomy for RCC, without macroscopic residual disease, with stage T3b-c,T4 or any pT and pN1 or pN2 or positive microscopic margins or microscopic vascular invasion, and no metastases were randomised to receive adjuvant treatment or observation. QoL was assessed by European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-30 (QLQC-30). Treatment delivery and toxicity were monitored. The trial was designed to detect an increase in 3year disease free survival (DFS) from 50% on observation to 65% on treatment (hazard ratio (HR)=0.63) with 90% power and two-sided alpha=0.05.

RESULTS

From 1998 to 2007, 309 patients were randomised (155 to observation; 154 to treatment). 35% did not complete the treatment, primarily due to toxicity (92% of patients experienced ⩾grade 2, 41% ⩾grade 3). Statistically significant differences between the arms in QoL parameters at 2months disappeared by 6months although there was suggestion of a persistent deficit in fatigue and physical function. Median follow-up was 7years (maximum 12.1years). 182 patients relapsed or died. DFS at 3years was 50% with observation and 61% with treatment (HR 0.84, 95% confidence interval (CI) 0.63-1.12, p=0.233). 124 patients died. Overall survival (OS) at 5years was 63% with observation and 70% with treatment (HR 0.87, 95% CI 0.61-1.23, p=0.428).

CONCLUSIONS

The treatment is associated with significant toxicity. There is no statistically significant benefit for the regimen in terms of disease free or overall survival.

Low faecal haemoglobin concentration potentially rules out significant colorectal disease

AIM

The study aimed to determine whether faecal haemoglobin (Hb) concentration can assist in deciding who with lower abdominal symptoms will benefit from endoscopy.

METHOD

Faecal Hb concentrations were measured on single samples from 280 patients referred for lower gastrointestinal tract endoscopy from primary care in NHS Tayside who completed a faecal immunochemical test (FIT) for Hb and underwent subsequent endoscopy.

RESULTS

Among 739 invited patients, FIT and endoscopy were completed by 280 (median age 63 (18-84) years; 59.6% women), with a median time between FIT and endoscopy of 9 days. Six (2.1%) participants had cancer, 23 (8.2%) had high-risk adenoma (HRA) (more than three adenomas or any > 1 cm), 31 (11.1%) low-risk adenoma (LRA) and 26 (9.3%) inflammatory bowel disease (IBD) as the most serious diagnosis. Those with cancer had a median faecal Hb of > 1000 ng Hb/ml buffer. Those with cancer + HRA + IBD had a median faecal Hb concentration of 75 ng Hb/ml buffer (95% CI 18-204), which was significantly higher than that of all remaining participants without significant colorectal disease (P < 0.0001). Using a cut-off faecal Hb concentration of 50 ng Hb/ml buffer, negative predictive values of 100.0%, 94.4%, 93.4% and 93.9% were found for cancer, HRA, LRA and IBD. Patients with reasons for referral other than rectal bleeding and family history did not have high faecal Hb concentrations.

CONCLUSION

Faecal Hb concentration measurements have considerable potential to contribute to reducing unnecessary endoscopy for the majority of symptomatic patients.

A wearable device for measuring eye dynamics in real-world conditions

Drowsiness and lapses of responsiveness have the potential to cause fatalities in many occupations. One subsystem of a prototype device which aims to detect these lapses as they occur is described. A head-mounted camera measures several features of the eye that are known to correlate with drowsiness. The system was tested with eight combinations of eye colour, ambient lighting, and eye glasses to simulate typical real-world input conditions. A task was completed for each set of conditions to simulate a range of eye movement-saccades, tracking, and eye closure. Our image processing software correctly classified 99.3% of video frames as open/closed/partly closed, and the error rate was not affected by the combinations of input conditions. Most errors occurred during eyelid movement. The accuracy of the pupil localisation was also not influenced by input conditions, with the possible exception of one subject's glasses.

Electromagnetic tomography via source-space-ICA

We propose a technique, called source-space-ICA to provide spatiotemporal reconstruction of brain sources. First, the weight-vector-normalized minimum variance beamformer is applied to reconstruct the electrical activity of a 3D scanning grid which covers the whole brain. Second, principal component analysis is used to reduce the dimension of the reconstructed signal matrix of the source-space, then independent component analysis (ICA) is applied on the resulting matrix to identify multiple signal sources in the source-space. Third, the demixing weight vectors obtained by ICA for the identified independent components are projected back into the SS to obtain tomographic maps of the sources. Besides localization, the proposed source-space-ICA approach reconstructs the time-course of each source in a single time-series without requiring prior knowledge of location, orientation, and number of sources for a given segment of EEG/MEG. Simulated EEG was used to evaluate the source-space-ICA. The results show that the source-space-ICA approach is able to separate and localize multiple weak sources and is robust to interference from other sources as it identifies the sources based on their statistical independence.

Performance of beamformers on EEG source reconstruction

Recently a number of new beamformers have been introduced for reconstruction and localization of neural sources from EEG and MEG. However, little is known about the relative performance of these beamformers. In this study, 8 scalar beamformers were examined with respect to several parameters to determine how effective they are at reconstruction of a dipole time course from EEG. A simulated EEG signal was produced by means of forward head modelling for projection of an artificial dipole on scalp electrodes then superimposed on background signal. Both real EEG and white noise were applied as background activity. Although the eigenspace beamformer can perform slightly better than other beamformers for small dipoles, and even more so for large dipoles, it is not a contender for real-time beamforming of EEG as it cannot be completely automated. Overall, in terms of performance, robustness to variations in parameters, and ease of application, the minimum variance and Borgiotti-Kaplan beamformers were found to be the best performers.

Mycophenolic acid area under the curve values in African American and Caucasian renal transplant patients are comparable

The possibility of an effect of ethnicity on the pharmacokinetics of mycophenolic acid, the immunosuppressive metabolite of the prodrug mycophenolate mofetil, was studied over 90 days following renal transplantation in African American (n = 13) and Caucasian patients (n = 20). Since renal dysfunction and time after transplant surgery are two factors known to alter mycophenolic acid pharmacokinetics, two-way analysis of variance of the data at each time point with ethnicity and renal function status as covariates was used to evaluate the possibility of an ethnicity effect on the pharmacokinetic parameters. No statistically significant difference based on ethnicity was detected for the primary pharmacokinetic parameters, abbreviated mycophenolic acid area under the concentration-time curve (MPA AUC), or the predose trough concentration on study days 4, 7, 14, 28, or 90. A statistically significant decrease in MPA AUC and increase in oral apparent clearance were observed in renally impaired patients regardless of ethnicity on days 4, and 4 and 7, respectively. The suggested mechanism for these differences is uremia-induced increased MPA free fraction, leading to a temporary increased clearance for this restrictively cleared drug.

Mycophenolic acid area under the curve values in African American and Caucasian renal transplant patients are comparable

The possibility of an effect of ethnicity on the pharmacokinetics of mycophenolic acid, the immunosuppressive metabolite of the prodrug mycophenolate mofetil, was studied over 90 days following renal transplantation in African American (n = 13) and Caucasian patients (n = 20). Since renal dysfunction and time after transplant surgery are two factors known to alter mycophenolic acid pharmacokinetics, two-way analysis of variance of the data at each time point with ethnicity and renal function status as covariates was used to evaluate the possibility of an ethnicity effect on the pharmacokinetic parameters. No statistically significant difference based on ethnicity was detected for the primary pharmacokinetic parameters, abbreviated mycophenolic acid area under the concentration-time curve (MPA AUC), or the predose trough concentration on study days 4, 7, 14, 28, or 90. A statistically significant decrease in MPA AUC and increase in oral apparent clearance were observed in renally impaired patients regardless of ethnicity on days 4, and 4 and 7, respectively. The suggested mechanism for these differences is uremia-induced increased MPA free fraction, leading to a temporary increased clearance for this restrictively cleared drug.