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Sukrong M, Prapaisilp P, Juntamongkol T, Siranart N, Phoolcharoen N, Assavapokee N, Sirisabya N, Santibenchakul S. Knowledge regarding human papillomavirus and cervical cancer prevention among medical students from Chulalongkorn University in Thailand. BMC Womens Health 2024; 24:129. [PMID: 38373946 PMCID: PMC10877815 DOI: 10.1186/s12905-024-02933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Cervical cancer is one of the leading causes of death among women in Thailand. General practitioners, within their primary healthcare role, play a vital role in the cervical cancer screening program, as they are the healthcare professionals most easily accessible to the general population. This study aims to determine the level of knowledge of cervical cancer and human papillomavirus (HPV) infection, HPV vaccination, and cervical cancer screening among last-year medical students. METHODS A cross-sectional study was conducted among sixth-year medical students using an electronic self-administered questionnaire. The two-part questionnaire comprised demographic data and 12 true/false questions that assessed knowledge regarding HPV infection, HPV vaccination, and cervical cancer screening recommendations. Pilot testing revealed a high Cronbach's alpha and test-retest reliability coefficient. RESULTS A 67% response rate was achieved. Among the 198 respondents, only one (0.5%) student correctly answered over 80% of the questions while most respondents (172, 71.7%) correctly answered less than 60% of the questions. Less than half of the respondents correctly identified crucial aspects such as the primary cause of cervical cancer, recommended vaccination age, cytology sensitivity compared to HPV testing, and the recommended screening frequency for average-risk women. CONCLUSIONS This study highlights a significant lack of comprehension among Thai medical students concerning HPV infection, vaccination, and cervical cancer screening guidelines. Encouraging educational enhancement, effective communication, and heightened awareness of these crucial topics within the medical school curriculum are imperative.
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Affiliation(s)
- Monchada Sukrong
- Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Peerapong Prapaisilp
- Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Tunchanok Juntamongkol
- Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Noppachai Siranart
- Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Natacha Phoolcharoen
- Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Nicha Assavapokee
- Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Nakarin Sirisabya
- Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
| | - Somsook Santibenchakul
- Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
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Phoolcharoen N, Areeruk W, Kantathavorn N, Tiyayon J, Chittithaworn S, Wetcho T, Satitniramai S, Khomphaiboonkij U, Pitakkarnkul S, Termrungruanglert W, Srisomboon J, Tangjitgamol S, Research Group TGCS. Self- and physician-collected high-risk human papillomavirus (HPV) testing to detect high-grade cervical lesions among Thai women. Int J Gynecol Cancer 2023; 33:1354-1358. [PMID: 37612037 DOI: 10.1136/ijgc-2023-004424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE We compared the performance of high-risk human papillomavirus (HPV) messenger RNA testing of physician- and self-collected specimens for detecting histological grade 2 or higher cervical intraepithelial neoplasia (CIN) among women who visited a colposcopy clinic in Thailand. METHODS From January 2022 to April 2022, 500 women participated in this cross-sectional multicenter study; 494 had complete data and valid specimen results. The participants were women who attended any one of the 10 participating institutes' colposcopy clinics due to abnormal cytology, positive high-risk HPV testing, or for follow-up. Participants used a self-sampling Aptima Multitest Swab specimen collection kit to self-collect vaginal samples before physicians biopsied the cervix during the colposcopic examination. The self- and physician-collected specimens were tested for high-risk HPV messenger RNA using Aptima nucleic acid amplification assays. Cervical tissues were collected during colposcopic-directed biopsy from the most severe lesion or a random biopsy and endocervical curettage specimen if no lesion was detected. RESULTS We detected high-risk HPV messenger RNA in 75.4% of self-collected specimens and 70.6% of physician-collected specimens. The prevalence of histological grade 2 or higher CIN from cervical histology was 25.1% (n=124). For self-collected specimens, the sensitivity and specificity of high-risk HPV messenger RNA for grade 2 or higher CIN were 87.0% (95% CI 79.7% to 92.4%; n=108) and 28.5% (95% CI 24.0% to 33.4%). For physician-collected specimens, the sensitivity and specificity of high-risk HPV messenger RNA for grade 2 or higher CIN were 90.2% (95% CI 83.6% to 94.9%; n=112) and 36.1% (95% CI 31.2% to 41.3%). CONCLUSIONS Self-collected specimens for high-risk HPV messenger RNA testing demonstrated good sensitivity and negative predictive value for detecting grade 2 or higher CIN in Thai women attending the participating institutes' colposcopy clinics. Self-collected samples performed similarly to physician-collected ones.
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Affiliation(s)
- Natacha Phoolcharoen
- Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wilasinee Areeruk
- Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nuttavut Kantathavorn
- Princess Srisavangavadhana College of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Jitima Tiyayon
- Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand
| | - Suwicha Chittithaworn
- Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanita Wetcho
- Princess Srisavangavadhana College of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Sikarn Satitniramai
- Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Wichai Termrungruanglert
- Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Siriwan Tangjitgamol
- Obstetrics and Gynecology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Kundrod KA, Jeronimo J, Vetter B, Maza M, Murenzi G, Phoolcharoen N, Castle PE. Toward 70% cervical cancer screening coverage: Technical challenges and opportunities to increase access to human papillomavirus (HPV) testing. PLOS Glob Public Health 2023; 3:e0001982. [PMID: 37585432 PMCID: PMC10431663 DOI: 10.1371/journal.pgph.0001982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
The World Health Organization (WHO) has called for the elimination of cervical cancer as a public health problem. Cervical cancer screening through human papillomavirus (HPV) testing is a core component of the strategy for elimination, with a set target of screening 70% of women twice in their lifetimes. In this review, we discuss technical barriers and opportunities to increase HPV screening globally.
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Affiliation(s)
- Kathryn A. Kundrod
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, United States of America
| | - Jose Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, United States of America
| | - Beatrice Vetter
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
| | - Mauricio Maza
- Department of Noncommunicable Diseases and Mental Health, Unit of Noncommunicable Diseases, Violence and Injury Prevention, Pan American Health Organization, Washington, DC, United States of America
| | - Gad Murenzi
- Einstein-Rwanda Research and Capacity Building Program, Research for Development Rwanda and Rwanda Military Hospital, Kigali, Rwanda
| | - Natacha Phoolcharoen
- Faculty of Medicine, Department of Obstetrics and Gynecology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Philip E. Castle
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, United States of America
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland, United States of America
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Batman S, Piya MK, Acharya SC, Lama P, Aryal B, Neupane M, Pariyar S, Phoolcharoen N, Eaton VJ, Sarchet V, Kremzier M, Baker E, Lopez M, Salcedo MP, Rodriguez J, Schmeler KM, Pariyar J. Cervical cancer prevention program in Nepal: A comprehensive "train the trainer" approach. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5530 Background: Cervical cancer is the leading cause of cancer and cancer-related deaths among women in Nepal, due in part to a lack of access to screening and limited medical providers trained to diagnose and treat women with preinvasive cervical disease. Cancer Care Nepal has partnered with The University of Texas MD Anderson Cancer Center (MD Anderson) and the American Society of Clinical Oncology (ASCO) to implement a ‘train the trainer’ (TOT) program to teach visual inspection with acetic acid (VIA), colposcopy, cervical biopsy, cryotherapy, thermal ablation, and loop electrosurgical excision procedure (LEEP). Methods: An initial cervical cancer prevention course was held in Kathmandu, Nepal in November 2019, supported by ASCO and with faculty from Civil Service Hospital, Bhaktapur Cancer Hospital, and National Academy of Medical Sciences and MD Anderson. As a continuation of this program, a TOT course was implemented for local specialists from five participating institutions throughout Nepal to learn how to deliver these trainings. Each participating institution then holds their own local course for nurses and doctors in their region. The training is complemented with monthly Project ECHO (Extension for Community Healthcare Outcomes) telementoring videoconferences. Results: The program was launched in November 2021. To date, two TOT training courses (2-day duration) have been held for clinicians from the 5 participating regions. Due to COVID-19 pandemic travel restrictions, didactic lectures were held virtually with MD Anderson and ASCO staff and included epidemiology of cervical cancer, screening guidelines, colposcopy, and treatment of cervical dysplasia. This was followed by hands-on training using simulation models to teach VIA, colposcopy, ablation and LEEP, led by the Nepalese faculty who had participated in the 2019 course. There were 41 participants in total (23 in the first course and 18 in the second course), including 21 gynecologists, 4 gynecologic oncologists, 1 medical oncologist, 1 general practitioner, and 14 nurses. 39 participants (73%) completed both the pre- and post- survey results. 86% of respondents from the first course and 100% of respondents from the second course reported that they intended to change their practice as a result of knowledge gained from the course. In addition, Cancer Care Nepal became a new hub for Project ECHO and held its first session in January 2022, with 20 participants representing two regions. The specialists from each of the 5 participating sites will be holding local courses for doctors and nurses in their respective regions throughout 2022. Conclusions: Our work shows that the TOT strategy can widen the reach of training in cervical cancer prevention in Nepal. Despite travel restrictions during the COVID-19 pandemic, global health training and mentoring can continue, though they require adaptions and use of virtual platforms.
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Affiliation(s)
| | | | | | | | - Binod Aryal
- Nepal Cancer Hospital and Research Center, Patan, Nepal
| | | | | | | | | | | | | | - Ellen Baker
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa Lopez
- University of Texas MD Anderson Cancer Center, Houston, TX
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de Oliveira CM, Salcedo MMP, Monteiro E, Mariano A, Verdinho MJC, Julião RDAM, Kundrod K, Smith C, Carns J, Andrade V, Baker E, Phoolcharoen N, Richards-Kortum RR, Fregnani JHTG, Schmeler KM, Lorenzoni C. HPV testing for cervical cancer screening in Mozambique: challenges and recommendations. Journal of Global Health Reports 2022. [DOI: 10.29392/001c.32432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Affiliation(s)
- Cristina M. de Oliveira
- Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil; Institute of Life and Health Sciences (ICVS), University of Minho, Braga, Portugal
| | - Mila M. P. Salcedo
- The Department of Gynecologic Oncology & Reproductive Medicine - The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre/Irmandade Santa Casa de Misericordia de Porto Alegre, Brazil
| | - Eliane Monteiro
- Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
| | - Arlete Mariano
- Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
| | | | | | | | | | | | - Viviane Andrade
- Research Support Center, Barretos Cancer Hospital, Barretos, Brazil
| | - Ellen Baker
- The Department of Gynecologic Oncology & Reproductive Medicine - The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- The Department of Gynecologic Oncology & Reproductive Medicine - The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | | | - Kathleen M. Schmeler
- The Department of Gynecologic Oncology & Reproductive Medicine - The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesaltina Lorenzoni
- Ministerio da Saúde de Moçambique (MISAU), Maputo, Mozambique; Universidade Eduardo Mondlane (UEM), Faculdade de Medicina, Maputo, Mozambique; Hospital Central de Maputo, Maputo, Mozambique
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Phoolcharoen N, Varon ML, Baker E, Parra S, Carns J, Cherry K, Smith C, Sonka T, Doughtie K, Lorenzoni C, Richards-Kortum R, Schmeler K, Salcedo MP. Hands-On Training Courses for Cervical Cancer Screening, Diagnosis, and Treatment Procedures in Low- and Middle-Income Countries. JCO Glob Oncol 2022; 8:e2100214. [PMID: 34985911 PMCID: PMC8769104 DOI: 10.1200/go.21.00214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
In 2018, there were approximately 570,000 new cases of cervical cancer worldwide. More than 85% of cases occurred in low- and middle-income countries (LMICs), primarily because of poor access to screening and a limited number of medical providers trained to diagnose and treat cervical precancerous lesions. Our objective was to provide locally arranged, hands-on training courses for medical providers in LMICs to learn to perform cervical cancer screening, diagnosis, and treatment procedures. The courses included didactic lectures and hands-on training stations using low-cost simulation models developed by bioengineers and students at Rice University in Houston, TX, United States, and the Malawi Polytechnic in Blantyre, Malawi. The hands-on training stations included visual inspection with acetic acid (VIA), colposcopy, cervical biopsy, endocervical curettage, loop electrosurgical excision procedure (LEEP), and thermal ablation. Provider pre- and postcourse confidence levels in performing the procedures were evaluated. From February 2017 to January 2020, we arranged 15 hands-on training courses in seven cities across six countries (El Salvador, Mozambique, Trinidad and Tobago, Lesotho, Malawi, and Nepal). Overall, there were 506 participants. The average number of participants per course was 38 (range 19-92). The participants included doctors, nurses, and midwives. The course duration varied from 1 to 3 days. Increased confidence in performing VIA, colposcopy and cervical biopsy, ablation, and LEEP was reported by 69%, 71%, 61%, and 76% of participants, respectively. Our findings suggest that locally arranged, hands-on cervical cancer prevention training courses in LMICs can improve provider confidence in performing cervical cancer screening, diagnosis, and treatment procedures. These courses are part of a larger strategy to build local capacity for delivering and improving cervical cancer prevention services in LMICs. Hands-on training courses improved provider confidence in cervical cancer screening, diagnostic and treatment in LMICs.![]()
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Affiliation(s)
- Natacha Phoolcharoen
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Melissa Lopez Varon
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ellen Baker
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sonia Parra
- Department of Bioengineering, Rice University, Houston, TX
| | - Jennifer Carns
- Department of Bioengineering, Rice University, Houston, TX
| | - Katelin Cherry
- Department of Bioengineering, Rice University, Houston, TX
| | - Chelsey Smith
- Department of Bioengineering, Rice University, Houston, TX
| | - Theresa Sonka
- Department of Bioengineering, Rice University, Houston, TX
| | - Kathleen Doughtie
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cesaltina Lorenzoni
- Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique.,Pathology Department, Hospital Central de Maputo, Maputo, Mozambique
| | | | - Kathleen Schmeler
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mila Pontremoli Salcedo
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Obstetrics and Gynecology, Federal University of Health Science of Porto Alegre (UFCSPA)/Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
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Ariyasriwatana C, Phoolcharoen N, Oranratanaphan S, Worasethsin P. Efficacy of Curcuminoids in managing postoperative pain after total laparoscopic hysterectomy: A randomized controlled, open-label trial. Complement Med Res 2022; 29:223-227. [PMID: 34986477 DOI: 10.1159/000521669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 12/23/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Curcuminoids, which are substances extracted from turmeric (Curcuma longa), have anti-inflammatory and analgesic effects and a good safety profile. This study aimed to evaluate the clinical efficacy of curcuminoid extracts on reducing pain among patients who underwent laparoscopic hysterectomy. Experimental procedure: From November 2016 to December 2017, 98 participants were included in this clinical trial, and they were randomly assigned to the experimental and control arms according to blocks of four. The intraoperative findings did not significantly differ between the two groups. The experimental group received one tablet of curcuminoid extract 250 mg four times a day on postoperative days 1-3. Pain was evaluated at 24 and 72 h postoperatively using a 10-point visual analog scale (VAS). RESULTS AND CONCLUSION The mean visual analog scale (VAS) scores at 24 h after surgery were 4.9 in the experimental group and 4.3 in the control group. Hence, the results did not significantly differ (p = 0.129). The mean VAS scores at 72 h after surgery were 1.8 in the experimental group and 2.8 in the control group (p = 0.001). The side effects in both groups were similar. Hence, curcuminoids can be an effective supplement for reducing pain after laparoscopic hysterectomy. The conclusion from this study is, that curcuminoids may be an effective supplement to reduce postoperative pain following laparoscopic hysterectomy.
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Affiliation(s)
- Chai Ariyasriwatana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natacha Phoolcharoen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Shina Oranratanaphan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pongkasem Worasethsin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Allanson ER, Phoolcharoen N, Salcedo MP, Fellman B, Schmeler KM. Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis. JCO Glob Oncol 2021; 7:1711-1721. [PMID: 34936374 PMCID: PMC8710337 DOI: 10.1200/go.21.00168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening. METHODS This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024. RESULTS Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I2 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I2 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I2 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I2 61.3%). CONCLUSION Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.
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Affiliation(s)
- Emma R Allanson
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Mila P Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre/Santa Casa Hospital of Porto Alegre, Porto Alegre, Brazil
| | - Bryan Fellman
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Phoolcharoen N, Kremzier M, Eaton V, Sarchet V, Acharya SC, Shrestha E, Carns J, Baker E, Varon ML, Karmacharya S, Aryal B, Richards-Kortum R, Salcedo MP, Schmeler KM, Pariyar J. American Society of Clinical Oncology (ASCO) Cervical Cancer Prevention Program: A Hands-On Training Course in Nepal. JCO Glob Oncol 2021; 7:204-209. [PMID: 33555914 PMCID: PMC8081534 DOI: 10.1200/go.20.00513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.
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Affiliation(s)
- Natacha Phoolcharoen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Megan Kremzier
- The American Society of Clinical Oncology (ASCO), Alexandria, VA
| | - Vanessa Eaton
- The American Society of Clinical Oncology (ASCO), Alexandria, VA
| | - Vanessa Sarchet
- The American Society of Clinical Oncology (ASCO), Alexandria, VA
| | | | | | - Jennifer Carns
- Department of Bioengineering, Rice University, Houston, TX
| | - Ellen Baker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa Lopez Varon
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Mila Pontremoli Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Obstetrics and Gynecology, Federal University of Health Science of Porto Alegre (UFCSPA)/Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Salcedo MP, Varon ML, Phoolcharoen N, Osman N, David E, Rangeiro R, Changule D, Andrade V, Neves A, Doughtie KM, Carns J, Lorenzoni C, Baker E, Schmeler KM. Building local capacity for cervical cancer prevention in low resource settings: Changing strategy during the COVID-19 pandemic. J Glob Health 2021; 11:03044. [PMID: 33763214 PMCID: PMC7956015 DOI: 10.7189/jogh.11.03044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mila P Salcedo
- The Obstetrics and Gynecology Department, Federal University of Health Sciences of Porto Alegre (UFCSPA)/ Santa Casa de Misericordia Hospital of Porto Alegre, Porto Alegre, Brazil.,The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa L Varon
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nafissa Osman
- Hospital Central de Maputo, Maputo, Mozambique.,Universidade Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Ernestina David
- Ministerio da Saude de Moçambique (MISAU), Maputo, Mozambique
| | | | | | | | | | - Kathleen M Doughtie
- The Department of Breast Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Carns
- Department of Bioengineering, Rice University, Houston, Texas, USA
| | - Cesaltina Lorenzoni
- Hospital Central de Maputo, Maputo, Mozambique.,Universidade Eduardo Mondlane (UEM), Maputo, Mozambique.,Ministerio da Saude de Moçambique (MISAU), Maputo, Mozambique
| | - Ellen Baker
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kathleen M Schmeler
- The Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Salcedo MP, Oliveira C, Andrade V, Mariano AAN, Changule D, Rangeiro R, Monteiro ECS, Baker E, Phoolcharoen N, Varon ML, Thomas JP, Castle PE, Fregnani JHTG, Schmeler KM, Lorenzoni C. The Capulana study: a prospective evaluation of cervical cancer screening using human papillomavirus testing in Mozambique. Int J Gynecol Cancer 2020; 30:1292-1297. [PMID: 32737122 DOI: 10.1136/ijgc-2020-001643] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer and related deaths among women in Mozambique. There is limited access to screening and few trained personnel to manage women with abnormal results. Our objective was to implement cervical cancer screening with human papillomavirus (HPV) testing, with navigation of women with abnormal results to appropriate diagnostic and treatment services. METHODS We prospectively enrolled women aged 30-49 years living in Maputo, Mozambique, from April 2018 to September 2019. All participants underwent a pelvic examination by a nurse, and a cervical sample was collected and tested for HPV using the careHPV test (Qiagen, Gaithersburg, Maryland, USA). HPV positive women were referred for cryotherapy or, if ineligible for cryotherapy, a loop electrosurgical excision procedure. Women with findings concerning for cancer were referred to the gynecologic oncology service. RESULTS Participants (n=898) had a median age of 38 years and 20.3% were women living with the human immunodeficiency virus. HPV positivity was 23.7% (95% confidence interval 21.0% to 26.6%); women living with human immunodeficiency virus were twice as likely to test positive for HPV as human immunodeficiency virus negative women (39.2% vs 19.9%, p<0.001). Most HPV positive women (194 of 213, 91.1%) completed all steps of their diagnostic work-up and treatment. Treatment included cryotherapy (n=158, 77.5%), loop electrosurgical excision procedure (n=30, 14.7%), or referral to a gynecologist or gynecologic oncologist (n=5, 2.5%). Of eight invasive cervical cancers, 5 (2.8%) were diagnosed in women living with human immunodeficiency virus and 3 (0.4%) in human immunodeficiency virus negative women (p=0.01). CONCLUSION Cervical cancer screening with HPV testing, including appropriate follow-up and treatment, was feasible in our study cohort in Mozambique. Women living with human immunodeficiency virus appear to be at a significantly higher risk for HPV infection and the development of invasive cervical cancer than human immunodeficiency virus negative women.
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Affiliation(s)
- Mila P Salcedo
- The Department of Obstetrics and Gynecology, Federal University of Health Science of Porto Alegre/Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil.,Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cristina Oliveira
- Life and Health Siences Research Institute (ICVS), University of Minho, Braga, Portugal.,Molecular Oncology Research Center, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
| | - Viviane Andrade
- Research Support Center of Teaching and Research Institute, Hospital de Cancer de Barretos, Barretos, São Paulo, Brazil
| | | | - Dércia Changule
- Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
| | | | | | - Ellen Baker
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Obstetrics and Gynecology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Melissa L Varon
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph P Thomas
- Department of Oncology Care and Research Information Systems, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Philip E Castle
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York, USA
| | | | - Kathleen M Schmeler
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesaltina Lorenzoni
- Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique.,Pathology Department, Hospital Central de Maputo, Maputo, Mozambique
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12
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Carroll MR, Ramalingam P, Salvo G, Fujimoto J, Solis Soto LM, Phoolcharoen N, Hillman RT, Cardnell R, Byers L, Frumovitz M. Evaluation of PARP and PDL-1 as potential therapeutic targets for women with high-grade neuroendocrine carcinomas of the cervix. Int J Gynecol Cancer 2020; 30:1303-1307. [PMID: 32727929 DOI: 10.1136/ijgc-2020-001649] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Women with recurrent high-grade neuroendocrine cervical cancer have few effective treatment options. The aim of this study was to identify potential therapeutic targets for women with this disease. METHODS Specimens from patients with high-grade neuroendocrine carcinomas of the cervix were identified from pathology files at MD Anderson Cancer Center. Immunohistochemical stains for PD-L1 (DAKO, clone 22-C3), mismatch repair proteins (MLH1, MSH2, MSH6, PMS2), somatostatin, and Poly (ADP-ribose) polymerase (PARP) were performed on sections from formalin-fixed paraffin-embedded tissue blocks. Nuclear PARP-1 staining was quantified using the H-score with a score of <40 considered low, 40-100 moderate, and ≥100 high. RESULTS Forty pathologic specimens from patients with high-grade neuroendocrine carcinomas of the cervix were examined (23 small cell, 5 large cell, 3 high-grade neuroendocrine, not otherwise specified, and 9 mixed). The mean age of the cohort was 43 years and the majority of patients (70%) were identified as white non-Hispanic. All 28 (100%) samples tested stained for mismatch repair proteins demonstrated intact expression, suggesting they were microsatellite stable tumors. Of the 31 samples tested for PD-L1 expression, only two (8%) of the 25 pure high-grade neuroendocrine carcinomas were positive whereas three (50%) of the six mixed carcinoma tumors tested positive. Of the 11 small cell specimens tested for PARP-1, 10 (91%) showed PARP expression with six (55%) demonstrating high expression and four (36%) showing moderate expression. Somatostatin staining was negative in 18 of 19 small cell cases (95%). CONCLUSIONS Pure high-grade neuroendocrine cervical carcinomas were microsatellite stable and overwhelmingly negative for PD-L1 expression. As the majority of tumors tested expressed PARP-1, inclusion of PARP inhibitors in future clinical trials may be considered.
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Affiliation(s)
| | | | - Gloria Salvo
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Junya Fujimoto
- Molecular and Translational Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Luisa Maren Solis Soto
- Molecular and Translational Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Natacha Phoolcharoen
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Tyler Hillman
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert Cardnell
- Thoracic/Head & Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lauren Byers
- Thoracic/Head & Neck Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Frumovitz
- Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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13
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Carroll M, Salvo G, Ramalingam P, Phoolcharoen N, Cardnell R, Byers L, Frumovitz M. PARP and PD-L1 as Potential Therapeutic Targets for Women with Neuroendocrine Cervical Cancer. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2019.11.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Phoolcharoen N, Kantathavorn N, Krisorakun W, Taepisitpong C, Krongthong W, Saeloo S. Acceptability of Self-Sample Human Papillomavirus Testing Among Thai Women Visiting a Colposcopy Clinic. J Community Health 2019; 43:611-615. [PMID: 29302852 DOI: 10.1007/s10900-017-0460-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We offered self-sampling devices to 250 women who visited the colposcopy clinic at Chulabhorn Hospital, Bangkok, Thailand from March 1 to June 30, 2015. Participants received instruction about the vaginal self-sample method and collected the specimen themselves, before being examined by the physician who obtained a conventional cervical specimen. Participating women's attitudes and feelings regarding the self-sample method were explored using a short questionnaire. Of the 247 eligible women, more than 90% of participants rated the self-sample method as very good to excellent for convenience, comfort, and safety. In addition, 80% of participants reported the overall experience of using the self-sample device was very good to excellent compared with the physician-collected method. Self-sample HPV testing appears to be highly accepted and perceived as convenient, comfortable, and safe. More studies on self-sample HPV testing should be conducted in Thailand to investigate this as an alternative method of cervical cancer screening, particularly among women who do not attend the screening program.
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Affiliation(s)
- Natacha Phoolcharoen
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand.
- Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 Rama IV Road, Pathum Wan, Bangkok, 10330, Thailand.
| | - Nuttavut Kantathavorn
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Wasanai Krisorakun
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Chantanee Taepisitpong
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Waraphorn Krongthong
- Data Management Unit, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Siriporn Saeloo
- Data Management Unit, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
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15
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Phoolcharoen N, Baker E, Lopez M, Bonongwe P, Parra S, Carns J, Cherry K, Munsell M, Thomas J, Smith C, Richards-Kortum R, Lorenzoni C, Salcedo M, Schmeler K. A hands-on training course for cervical cancer screening and management of pre-invasive disease in Lesotho, Africa. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Phoolcharoen N, Oranratanaphan S, Ariyasriwatana C, Worasethsin P. Efficacy of curcuminoids for reducing postoperative pain after laparoscopic gynecologic surgery: A pilot randomized trial. J Complement Integr Med 2019; 16:/j/jcim.ahead-of-print/jcim-2018-0224/jcim-2018-0224.xml. [PMID: 31150356 DOI: 10.1515/jcim-2018-0224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/20/2019] [Indexed: 12/31/2022]
Abstract
Background Curcuminoids, which are substances extracted from turmeric, have been proved to have anti-inflammatory and analgesic effects along with a good safety profile. This study aimed to evaluate the clinical efficacy of curcuminoids for reducing postoperative pain in patients who undergo laparoscopic gynecologic surgery. Methods From November 2016 to December 2017, participants were randomly assigned, by blocks of four, to the intervention and control arms of the study. Altogether, 60 patients who were to undergo laparoscopic gynecologic surgery at our institution were enrolled. Intraoperative findings were not significantly different between the two groups. One tablet of curcuminoid extract 250 mg was given to patients in the intervention group four times a day on postoperative days 1-3. Pain was evaluated at 24 and 72 h postoperatively using a 10-point visual analog scale (VAS). Results The median VAS score 24 h after surgery was 3 (1-6) in the intervention group and 4.5 (3-7) in the control group, with the difference reaching statistical significance (p=0.001). The median VAS at 72 h after surgery was 1 (0-2) in the intervention group and 2 (1-5) in the control group (p<0.001). Conclusion Curcuminoids may be an effective supplement to reduce pain severity postoperatively following laparoscopic gynecologic surgery. Trial Registration TCTR20180215001 www.clinicaltrials.in.th.
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Affiliation(s)
- Natacha Phoolcharoen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Shina Oranratanaphan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chai Ariyasriwatana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pongkasem Worasethsin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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17
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Sompratthana T, Phoolcharoen N, Schmeler KM, Lertkhachonsuk R. End-of-life symptoms and interventions among women with gynecologic cancers in a tertiary-care hospital in Thailand. Int J Gynecol Cancer 2019; 29:ijgc-2019-000338. [PMID: 31079059 DOI: 10.1136/ijgc-2019-000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Studies have shown improved patient quality of life with supportive care rather than aggressive treatment at the end of life. This study evaluated the symptoms that patients in Thailand with gynecologic cancers experienced and the interventions that they received at the end of life. METHODS The medical records of patients admitted to a tertiary cancer center in Thailand who died in the hospital from gynecologic malignancies between January 1, 2011 and December 31, 2016 were reviewed. Inclusion criteria were patients who had been been diagnosed with gynecologic cancers (ovarian, endometrial, cervical, vulvar, or peritoneal cancers or uterine sarcomas) and had died in the hospital during that period. Patients whose medical records were incomplete or unavailable were excluded from the study. Data on demographics, symptoms, interventions, and end-of-life care were collected. RESULTS A total of 159 patients were included in this analysis. The mean age at death was 54.3 (range 15-91) years. Over half (54.7%) of the patients were diagnosed with ovarian or peritoneal cancer, 26.4% with uterine cancer or sarcoma, 16.4% with cervical cancer, and 1.3% with dual primary cancers. Symptoms at time of admission were poor oral intake (68.6%), abdominal distention or discomfort (63.5%), pain (42.8%), nausea or vomiting (35.2%), and fever or signs of infection (27.0%). The mean number of hospitalizations during the last 6 months was 3.6. Thirty-six patients (22.6%) had major surgery during the last 6 months of life, with 14 patients (8.8%) having it performed during their last admission before death. The mean length of the last hospital stay was 22.3 (range 6-31) days, and 61 patients (38.4%) were admitted to the intensive care unit. Eleven patients (6.9%) had chemotherapy in their last 14 days of life and 10 (6.3%) received cardiopulmonary resuscitation. Almost all patients (153, 96.2%) had do-not-resuscitate (DNR) consents. The mean time between the DNR consent and death was 6.3±9.7 days. CONCLUSION Multiple hospital admissions, aggressive treatments, and invasive procedures were common among patients with gynecologic cancer at the end of life. Better symptom management, end-of-life preparation, and communication are needed to enhance patients' quality of life in Thailand.
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Affiliation(s)
- Thanchanok Sompratthana
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natacha Phoolcharoen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ruangsak Lertkhachonsuk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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18
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Chokchaichamnankit D, Watcharatanyatip K, Subhasitanont P, Weeraphan C, Keeratichamroen S, Sritana N, Kantathavorn N, Diskul-Na-Ayudthaya P, Saharat K, Chantaraamporn J, Verathamjamras C, Phoolcharoen N, Wiriyaukaradecha K, Paricharttanakul NM, Udomchaiprasertkul W, Sricharunrat T, Auewarakul C, Svasti J, Srisomsap C. Urinary biomarkers for the diagnosis of cervical cancer by quantitative label-free mass spectrometry analysis. Oncol Lett 2019; 17:5453-5468. [PMID: 31186765 PMCID: PMC6507435 DOI: 10.3892/ol.2019.10227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 03/27/2019] [Indexed: 12/15/2022] Open
Abstract
Due to the invasive procedure associated with Pap smears for diagnosing cervical cancer and the conservative culture of developing countries, identifying less invasive biomarkers is of great interest. Quantitative label-free mass spectrometry was performed to identify potential biomarkers in the urine samples of patients with cervical cancer. This technique was used to study the differential expression of urinary proteomes between normal individuals and cancer patients. The alterations in the levels of urinary proteomes in normal and cancer patients were analyzed by Progenesis label-free software and the results revealed that 60 proteins were upregulated while 73 proteins were downregulated in patients with cervical cancer. This method could enrich high molecular weight proteins from 100 kDa. The protein-protein interactions were obtained by Search Tool for the Retrieval of Interacting Genes/Proteins analysis and predicted the biological pathways involving various functions including cell-cell adhesion, blood coagulation, metabolic processes, stress response and the regulation of morphogenesis. Two notable upregulated urinary proteins were leucine-rich α-2-glycoprotein (LRG1) and isoform-1 of multimerin-1 (MMRN1), while the 3 notable downregulated proteins were S100 calcium-binding protein A8 (S100A8), serpin B3 (SERPINB3) and cluster of differentiation-44 antigen (CD44). The validation of these 5 proteins was performed by western blot analysis and the biomarker sensitivity of these proteins was analyzed individually and in combination with receiver operator characteristic curve (ROC) analysis. Quantitative mass spectrometry analysis may allow for the identification of urinary proteins of high molecular weight. The proteins MMRN1 and LRG1 were presented, for the first time, to be highly expressed urinary proteins in cervical cancer. ROC analysis revealed that LRG1 and SERPINB3 could be individually used, and these 5 proteins could also be combined, to detect the occurrence of cervical cancer.
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Affiliation(s)
| | | | | | - Churat Weeraphan
- Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210, Thailand.,Department of Molecular Biotechnology and Bioinformatics Faculty of Science, Prince of Songkla University, Songkla 90110, Thailand
| | | | - Narongrit Sritana
- Molecular and Genomic Research Laboratory, Research and International Relations Division, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Nuttavut Kantathavorn
- Gynecologic Oncology Unit, Woman Health Center, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | | | - Kittirat Saharat
- Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210, Thailand
| | | | - Chris Verathamjamras
- Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210, Thailand
| | - Natacha Phoolcharoen
- Gynecologic Oncology Unit, Woman Health Center, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Kriangpol Wiriyaukaradecha
- Molecular and Genomic Research Laboratory, Research and International Relations Division, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | | | - Wandee Udomchaiprasertkul
- Molecular and Genomic Research Laboratory, Research and International Relations Division, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Thaniya Sricharunrat
- Pathology Laboratory Unit, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Chirayu Auewarakul
- Research and International Relations Division, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok 10210, Thailand.,Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Jisnuson Svasti
- Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210, Thailand.,Applied Biological Sciences Program, Chulabhorn Graduate Institute, Bangkok 10210, Thailand
| | - Chantragan Srisomsap
- Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210, Thailand
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19
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Phoolcharoen N, Kantathavorn N, Krisorakun W, Sricharunrat T, Teerayathanakul N, Taepisitpong C, Sornsamdang G, Krongthong W, Saeloo S. Agreement of self- and physician-collected samples for detection of high-risk human papillomavirus infections in women attending a colposcopy clinic in Thailand. BMC Res Notes 2018; 11:136. [PMID: 29458440 PMCID: PMC5819229 DOI: 10.1186/s13104-018-3241-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
Objective To study the concordance between vaginal self- and endocervical physician-collected high-risk (hr) HPV testing in Thai women who attended a colposcopy clinic. Vaginal samples were obtained by self-sampling with a dry brush before endocervical samples were obtained by physicians. Both specimens were analyzed for hrHPV by Cobas4800 HPV test. Results Of the 247 pairs of samples, overall hrHPV prevalence from self- and physician-collected samples was 41.3 and 36.0%, respectively. The overall agreement between the methods was 74.5% with κ 0.46 (P < 0.001). Our study revealed moderate agreement between self- and physician-collected methods for hrHPV testing.
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Affiliation(s)
- Natacha Phoolcharoen
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand. .,Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathum Wan, Bangkok, 10330, Thailand.
| | - Nuttavut Kantathavorn
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Wasanai Krisorakun
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Thaniya Sricharunrat
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Narongchai Teerayathanakul
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Chantanee Taepisitpong
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Gaidganok Sornsamdang
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Waraphorn Krongthong
- Data Management Unit, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Siriporn Saeloo
- Data Management Unit, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand
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20
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Phoolcharoen N, Kantathavorn N, Sricharunrat T, Saeloo S, Krongthong W. A population-based study of cervical cytology findings and human papillomavirus infection in a suburban area of Thailand. Gynecol Oncol Rep 2017; 21:73-77. [PMID: 28725677 PMCID: PMC5506866 DOI: 10.1016/j.gore.2017.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/14/2017] [Accepted: 06/02/2017] [Indexed: 11/17/2022] Open
Abstract
Despite the high incidence of cervical cancer in Thailand, large population-based studies on cervical cytology and HPV prevalence and genotype distribution are rare. This study aimed to determine cervical cytology results and the prevalence and distribution of HPV among Thai females in Bangkhayaeng subdistrict, Pathumthani province, Thailand. Of 4681 female inhabitants, aged 20–70 years, 1523 women finally participated in the study. Cervical samples using liquid-based cytology were collected during February–August 2013 and analyzed for HPV genotype by the LINEAR ARRAY® HPV Genotyping Test (Roche, USA). All participants with abnormal cytology or HPV positivity underwent colposcopy and biopsy. Of 1523 eligible women, 4.1% had abnormal cytology including ASC-US (2.4%), LSIL (1.0%), and HSIL (0.5%). The HPV infection rate was 13.7%. The prevalences of high-risk, probable high-risk, and low-risk HPV types were 5.6%, 3.5%, and 6.8%, respectively. The most common high-risk HPV types detected were HPV-16 (1.31%), HPV-51 (1.25%), and HPV-52 (1.25%). The most common probable high-risk and low-risk HPV types detected were HPV-72 (1.51%), HPV-62 (1.38%), and HPV-70 (1.18%). The rates of CIN2–3 and cancer in this cohort were 1.4% and 0.3%, respectively. In conclusion, HPV prevalence in this study was lower than reported in studies conducted in Western countries or other Asia countries, despite the high prevalence of CIN2 + and cancer. HPV type screening results of the general population in Bangkhayaeng subdistrict were similar to those reported in other countries, with HPV-16 the most common type. However, higher frequencies of HPV-51 and HPV-52 were observed. Despite the availability of a free screening program in this area, the participation rate remains low. The largest population-based study using liquid-based cytology and Linear array HPV genotyping in Thailand. Low prevalence of high risk HPV in Thailand despite high incidence of cervical cancer. Higher ratio of HPV-51, HPV-52 after HPV-16 in this cohort. Almost abnormal results underwent colposcopy and biopsy with histological confirmation.
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Affiliation(s)
- Natacha Phoolcharoen
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, 54 Kamphaengphet 6 Road, Laksi, Bangkok 10210, Thailand
| | - Nuttavut Kantathavorn
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, 54 Kamphaengphet 6 Road, Laksi, Bangkok 10210, Thailand
| | - Thaniya Sricharunrat
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, 54 Kamphaengphet 6 Road, Laksi, Bangkok 10210, Thailand
| | - Siriporn Saeloo
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, 54 Kamphaengphet 6 Road, Laksi, Bangkok 10210, Thailand
| | - Waraphorn Krongthong
- Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, 54 Kamphaengphet 6 Road, Laksi, Bangkok 10210, Thailand
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Chaowawanit W, Tangjitgamol S, Kantathavorn N, Phoolcharoen N, Kittisiam T, Khunnarong J, Supawattanabodee B, Srijaipracharoen S, Thavaramara T, Pataradool K. Knowledge, Attitudes and Behavior of Bangkok Metropolitan Women Regarding Cervical Cancer Screening. Asian Pac J Cancer Prev 2017; 17:945-52. [PMID: 27039818 DOI: 10.7314/apjcp.2016.17.3.945] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To assess knowledge, attitudes and cervical cancer screening behavior of Bangkok Metropolitan women. MATERIALS AND METHODS Thai women, aged 25-to-65 years old, having lived in Bangkok for 5 years or more were invited to participate in the study. After signing informed consent, all women were asked to complete a self-questionnaire (Thai language) with literate assistance if needed. The questionnaire was divided into 3 parts: (I) demographic data; (II) knowledge about cervical cancer screening; and (III) behavior and attitudes, towards cervical cancer screening. Adequate screening was defined as women who had ≥two cervical cancer screening tests except women aged 25-30 years who may have only one screening, and the last screen was within 5 year or had had regular screening. RESULTS Of 4,339 women, there were 1,857 (42.8%) with adequate screening and 2,482 (57.2%) with inadequate screening. Significant factors associated with inadequate screening included age < 45 years, pre-menopausal status, family monthly income <625 USD, no reported sexual intercourse, nulliparous, no knowledge, lack of awareness and poor attitudes. Three major reasons provided by women for inadequate screening were no symptoms (54.4%), fear of pain (33.2%), and embarrassment (34.6%). CONCLUSIONS Personal features, knowledge, and attitudes influence screening behavior of Bangkok Metropolitan women. The three most common reasons of women for not undergoinging screening are no symptoms, fear of pain, and embarrassment. These factors should be the focus of attention to improve coverage of cervical cancer screening in Bangkok.
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Affiliation(s)
- Woraphot Chaowawanit
- Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand E-mail :
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Tangjitgamol S, Kantathavorn N, Kittisiam T, Chaowawanit W, Phoolcharoen N, Manusirivithaya S, Khunnarong J, Srijaipracharoen S, Saeloo S, Krongthong W, Supawattanabodee B, Thavaramara T, Pataradool K. Prevalence and Associated Factors of Abnormal Cervical Cytology and HighRisk HPV DNA among Bangkok Metropolitan Women. Asian Pac J Cancer Prev 2016; 17:3147-3153. [PMID: 27509943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Many strategies are required for cervical cancer reduction e.g. provision of education cautious sexual behavior, HPV vaccination, and early detection of preinvasive cervical lesions and invasive cancer. Basic health data for cervical cytology/ HPV DNA and associated factors are important to make an appropriate policy to fight against cervical cancer. AIMS To assess the prevalence of abnormal cervical cytology and/or HPV DNA and associated factors, including sexual behavior, among Bangkok Metropolitan women. MATERIALS AND METHODS Thai women, aged 25to65 years old, had lived in Bangkok for ≥5 years were invited into the study. Liquidbased cervical cytology and HPV DNA tests were performed. Personal data were collected. MAIN OUTCOMES MEASURES Rates of abnormal cytology and/ or highrisk HPV (HRHPV) and factors associated with abnormal test(s) were studied. RESULTS Abnormal cytology and positive HRHPV were found in 6.3% (279/4442 women) and 6.7% (295/4428), respectively. The most common abnormal cytology was ASCUS (3.5%) while the most common HRHPV genotype was HPV 16 (1.4%) followed by HPV 52 (1.0%), HPV 58 (0.9%), and HPV 18 and HPV 51 at equal frequency (0.7%). Both tests were abnormal in 1.6% (71/4428 women). Rates of HRHPV detection were directly associated with severity of abnormal cytology: 5.4% among normal cytology and 13.0%, 30.8%, 40.0%, 39.5%, 56.3% and 100.0% among ASCUS, ASCH, AGCNOS, LSIL, HSIL, and SCC, respectively. Some 5% of women who had no HRHPV had abnormal cytology, in which 0.3% had ≥ HSIL. Factors associated with abnormal cytology or HRHPV were: age ≤40 years, education lower than (for cytology) or higher than bachelor for HRHPV), history of sexual intercourse, and sexual partners ≥2. CONCLUSIONS Rates for abnormal cytology and HRHPV detection were 6.3% and 6.7% HRHPV detection was directly associated with severity of abnormal cytology. Significant associated factors were age ≤40 years, lower education, history of sexual intercourse, and sexual partners ≥2.
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Affiliation(s)
- Siriwan Tangjitgamol
- Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand Email :
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Kantathavorn N, Mahidol C, Sritana N, Sricharunrat T, Phoolcharoen N, Auewarakul C, Teerayathanakul N, Taepisitpong C, Saeloo S, Sornsamdang G, Udomchaiprasertkul W, Krongthong W, Arnamwong A. Genotypic distribution of human papillomavirus (HPV) and cervical cytology findings in 5906 Thai women undergoing cervical cancer screening programs. Infect Agent Cancer 2015; 10:7. [PMID: 25737740 PMCID: PMC4347911 DOI: 10.1186/s13027-015-0001-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 01/30/2015] [Indexed: 01/04/2023] Open
Abstract
Background Cervical cancer is the major cause of morbidity and mortality in Thai women. Nevertheless, the preventive strategy such as HPV vaccination program has not been implemented at the national level. This study explored the HPV prevalence and genotypic distribution in a large cohort of Thai women. Methods A hospital-based cervical cancer screening program at Chulabhorn Hospital, Bangkok and a population-based screening program at a rural Pathum Thani Province were conducted using liquid-based cytology and HPV genotyping. Results Of 5906 women aged 20–70 years, Pap smear was abnormal in 4.9% and the overall HPV prevalence was 15.1%, with 6.4% high-risk (HR), 3.5% probable high-risk (PR), and 8.4% low-risk (LR) HPV. The prevalence and genotypic distribution were not significantly different between the two cohorts. Among HR-HPV genotypes, HPV52 was the most frequent (1.6%), followed by HPV16 (1.4%), HPV51 (0.9%), HPV58 (0.8%), HPV18 (0.6%), and HPV39 (0.6%). Among LR-HPV genotypes, HPV72 and HPV62 were the most frequent while HPV6 and HPV11 were rare. HPV infection was found to be proportionately high in young women, aged 20–30 years (25%) and decreasing with age (11% in women aged >50). The more severe abnormal cytology results, the higher positivity of HR-HPV infection was observed. Conclusions In conclusion, HPV52, HPV16, and HPV51 were identified as the most common HR-HPV genotypes in Thai women. This study contributes genotypic evidence that should be essential for the development of appropriate HPV vaccination program as part of Thailand’s cervical cancer prevention strategies.
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Affiliation(s)
- Nuttavut Kantathavorn
- Chulabhorn Hospital, Bangkok, Thailand ; Gynecologic Oncology Unit, Chulabhorn Hospital, 54 Kamphaengphet 6 Road, Laksi, Bangkok, 10210 Thailand
| | - Chulabhorn Mahidol
- Chulabhorn Hospital, Bangkok, Thailand ; Chulabhorn Research Institute, Bangkok, Thailand ; Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Natacha Phoolcharoen
- Chulabhorn Hospital, Bangkok, Thailand ; Gynecologic Oncology Unit, Chulabhorn Hospital, 54 Kamphaengphet 6 Road, Laksi, Bangkok, 10210 Thailand
| | - Chirayu Auewarakul
- Chulabhorn Hospital, Bangkok, Thailand ; Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kantathavorn N, Phoolcharoen N, Laebua K, Chamchod S, Pattaranutaporn P, Trirussapanich P, Rojwatkarnjana S, Udomchaiprasertkul W, Saeloo S, Krongthong W. HPV prevalence and genotypic distribution in patients with cervical cancer in Bangkok, Thailand. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e12510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Phoolcharoen N, Nilgate S, Rattanapuntamanee O, Limpongsanurak S, Chaithongwongwatthana S. A randomized controlled trial comparing ceftriaxone with cefazolin for antibiotic prophylaxis in abdominal hysterectomy. Int J Gynaecol Obstet 2012; 119:11-3. [DOI: 10.1016/j.ijgo.2012.04.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 04/18/2012] [Accepted: 06/14/2012] [Indexed: 11/24/2022]
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