Gaps and Opportunities to Improve Prevention of Human Papillomavirus-Related Cancers

Human papillomavirus (HPV) infections cause more than 35,900 cancers annually in the United States. Although cervical cancer is the most prevalent HPV-related malignancy in women, the virus is also responsible for a significant percentage of anal, vaginal, and vulvar cancers. A comprehensive approach to mitigating cervical cancer includes HPV vaccination (primary prevention), screening and treatment of precancerous lesions (secondary prevention), and diagnosis and treatment of invasive cancer (tertiary prevention). Although a successful strategy, there are opportunities to innovate and increase access that can also be adapted to address the unique clinical care gaps that exist with the other anogenital cancers. The Society for Women's Health Research held a series of interdisciplinary meetings and events, during which expert researchers, clinicians, patient advocates, and health care policy leaders evaluated the current landscape of HPV-related cancers and their effects on women's health. This report summarizes the discussions of this working group and areas it identified in which to address gaps in primary and secondary prevention approaches to improve access and health outcomes for women with HPV-related anogenital cancers.

Frequency of cervical cancer and breast cancer screening in HIV-infected women in a county-based HIV clinic in the Western United States

BACKGROUND

Women's primary-care services are frequently dispensed to HIV-infected women through HIV specialty clinics. Our objective was to evaluate cervical cancer and breast cancer screening practices in a county-based HIV clinic in San Mateo, California.

METHODS

This was a retrospective cohort study of medical records of HIV-infected women obtaining HIV care at this site.

RESULTS

Between January 1, 2002 and December 31, 2006, 69 women were documented to have at least 12 months of medical care at the clinic. Median followup time was 51 months. Over 253 person-years of followup, there were 656 pap smears performed per 1,000 person-years; 77.9% of women had at least one Pap smear during the study time period. A total of 59.5% (47/79) of normal pap smears had a followup pap smear within 18 months; 62.0% of abnormal pap smears had a followup pap smear within 12 months. A CD4 count of less than 200 cells/mm(3) was associated with not receiving a pap smear in multivariable analysis. Mammogram screening was performed on 64.7% of women aged 40 or older.

CONCLUSIONS

Based on the results of this study, the majority of HIV-infected women at this clinic received cervical and breast cancer screening at some point during their care. Only two-thirds of abnormal pap smear results had followup pap smear screening within a year. With the increased risk of cervical cancer in HIV-infected women, efforts should be made to promote cervical cancer screening, particularly in high-risk women.

A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding

OBJECTIVES

Abnormal uterine bleeding (AUB) impacts women's health-related quality of life (HRQoL) and puts a heavy economic burden on society. To date, this burden has not been systematically studied. We conducted a systematic review of the medical literature to evaluate the impact of AUB on HRQoL and to quantify the economic burden of AUB from a societal perspective.

METHODS

We searched the PubMed and Cochrane databases, and article bibliographies for the period up to July 2005. Teams of two reviewers independently abstracted data from studies that reported outcomes of interest: prevalence, HRQoL, work impairment, and health-care utilization and costs associated with AUB.

RESULTS

The search yielded 1009 English-language articles. Ninety-eight studies (including randomized controlled trials, observational studies, and reviews) that met the inclusion and exclusion criteria underwent a full-text review. The prevalence of AUB among women of reproductive age ranged from 10% to 30%. The HRQoL scores from the 36-item Short-Form Health Survey Questionnaire (SF-36) suggested that women with AUB have HRQoL below the 25th percentile of that for the general female population within a similar age range. The conservatively estimated annual direct and indirect economic costs of AUB were approximately $1 billion and $12 billion, respectively. These figures do not account for intangible costs and productivity loss due to presenteeism.

CONCLUSIONS

The burden of AUB needs further and more thorough investigation. Additional research should prospectively evaluate the impact of AUB and the value of treatment provided to help guide future health resource allocation and clinical decision-making.

Digital assessment of the reproductive tract (DART)

As the AIDS epidemic grows through heterosexual transmission, the development of women-controlled methods for defence against sexually transmitted infections and HIV, such as vaginally applied microbicides, is increasingly important. As part of the evaluation of the safety of all new topical microbicides, an evaluation of the cervix and vagina for any physical or mechanical effects of a potential agent is imperative. Traditionally, colposcopy has been used for such an evaluation. We introduce the concept of using a digital camera to assess the reproductive tract as a practical and effective means for studying the effects of microbicides on the vaginal and cervical epithelium. As much research on microbicides will be undertaken in areas with limited resources, digital assessment of the reproductive tract offers the advantage of portability, ease of use, durability, and accessibility. In addition, it allows digital data storage that can be used to review images, allow quality control, and provide an effective means to compare changes over time.

Sensitive methods to detect epithelial disruption: tests for microhemorrhage in cervicovaginal lavages

The toxic effects of topical microbicides might include epithelial disruption, and if sufficiently severe, may cause visible bleeding. We have developed two sensitive methods to detect hemorrhage far below the visual detection threshold: an enzyme-linked immunosorbent assay for human hemoglobin and a method for staining and enumerating red blood cells by fluorescent microscopy. We have applied these methods to cervicovaginal and introital lavages, and found them to be sensitive and quantitative over a broad range. Comparing the new techniques with a standard heme-detection assay (Hemastix) we found them to be more sensitive, more objective, more fully quantitative, and more likely to be indicative of recent events. In pilot studies we found that the red blood cell and hemoglobin concentrations in samples taken in the luteal phase of the menstrual cycle are low, but still within the detection range of the new assays, providing a quantifiable baseline from which increases in blood from epithelial disruption can be detected and quantified. We propose that these new methods may be used for the safety assessment of microbicides by detecting and quantifying microhemorrhage in cervicovaginal secretions before and after exposure to microbicide.

Oral contraceptives and cervical cancer: critique of a recent review

A recent review article by Smith et al. in The Lancet purports to find a causal relationship between long-term use of oral contraceptives (OCs) and cervical cancer. While we endorse the search for such a relationship, we felt it important to critically examine Smith et al.'s review process and, as a result, we have questions about the validity of their conclusions. In our view, the findings of published articles as presented by Smith et al. do not confirm a causal connection between long-term use of OCs and cervical cancer. Our goal is not to conduct another formal review of the evidence, but to evaluate whether Smith et al. have met the burden of proof for establishing a causal relationship. Given the importance of OCs to women the world over, we urge reproductive health professionals to consider this issue carefully before accepting that a causal relationship exists.

Are partners available for post-abortion contraceptive counseling? A pilot study in a Baltimore City clinic

About half of the 1.2 million abortions each year in the United States are repeat abortions. While most abortion providers counsel women about contraception, one reason for the high repeat rate could be failure to take into account the social context of the women--in particular, the male partner. To assess whether there might be a window of opportunity for a contraceptive intervention that includes the male partner at the time of the abortion, we undertook a pilot study at an urban abortion clinic to examine the role of the male partner among women receiving abortions. Between May 2001 and August 2002, two questionnaires were administered to 109 women receiving abortions in a Baltimore City clinic. On the procedure day, women were more likely to be accompanied by a male partner upon arrival (30%) or when leaving (34%) than by any other individual. The majority of women receiving abortions reported that their partners played positive decision-making and support roles throughout the abortion process. A significant proportion of couples could be available for contraceptive counseling following an abortion, providing rationale for couples' post-abortion contraceptive counseling for women whose partners are already actively and positively involved in the abortion process. Such an intervention may help to reduce repeat abortions.

The Filshie clip for laparoscopic adnexal surgery

BACKGROUND

Gynecologic endoscopic procedures are increasingly common and require the ability to control large vascular structures.

METHOD

The Filshie clip is a silicone-lined, titanium occlusive device, originally designed and Food and Drug Administration (FDA) approved for surgical contraception. This device also has the potential for occluding vascular structures during laparoscopic surgery.

EXPERIENCE AND RESULTS

We describe a salpingectomy, an excision of bilateral hydrosalpinges, and a salpingo-oopherectomy. We performed all procedures laparoscopically using this device as the primary modality for assuring hemostasis.

CONCLUSION

The Filshie clip is a useful and economical device for assuring hemostasis during gynecologic endoscopic surgery.

The "boom and bust phenomenon": the hopes, dreams, and broken promises of the contraceptive revolution

The "boom and bust phenomenon" is a pattern that has emerged in the development, introduction, and delivery of a number of significant new contraceptive products in the United States. When a new contraceptive product is introduced with great promise and publicity, it usually experiences a "boom" during which sales, demand, and expectations are high. This boom is often followed by a "bust" phase during which a product does not live up to expectations, initial excitement falls off, and a drop in sales and use ensues. The boom and bust phenomenon goes to the heart of what some have referred to as the failed promise of the contraception revolution by creating obstacles to significant expansion of contraceptive choice in the United States. Case studies of oral contraceptives, intrauterine devices, and Norplant(R) are used to illustrate the boom and bust phenomenon and the effect it has had in shaping the direction of advances in contraceptive technology.

Lea's Shield: a study of the safety and efficacy of a new vaginal barrier contraceptive used with and without spermicide

The purpose of this study was to evaluate the safety, efficacy and acceptability of Lea's Shield, a new vaginal contraceptive barrier device, when used with either spermicidal or non-spermicidal lubricant. One-hundred-eighty-five (185) women enrolled at six centers. Half were randomized to use the device with spermicide and half with a non-spermicidal lubricant. To be eligible, volunteers had to be 18-40 years old (inclusive), in good health with regular menses, sexually active in an ongoing relationship and at risk for pregnancy, and willing to use Lea's Shield as their sole means of contraception for six months. Participants were seen at admission, one week, one month, three months and six months. Gross cumulative life table rates were calculated for pregnancy and others reasons for discontinuation. Adverse experiences and responses to an acceptability questionnaire were evaluated. One-hundred-eighty-two (182) volunteers contributed data to the analysis of safety and 146 to that of contraceptive efficacy. The unadjusted six-month life table pregnancy rate was 8.7 per 100 women for spermicide users and 12.9 for non-spermicide users (p = 0.287). After controlling for age, center, and frequent prior use of barrier methods, the adjusted six-month life table pregnancy rate was 5.6 for spermicide users and 9.3 for non-spermicide users (p = 0.086), indicating that use of spermicide lowered pregnancy rates, although not significantly, during typical use. For purposes of comparison, it is important to note that this study differed from the cap/diaphragm and sponge/ diaphragm studies in that a high percentage (84%) of volunteers were parous. For reasons that are unclear, pregnancy rates among parous women using barrier contraceptives tend to be higher than among nulliparous women. Indeed, in this study there were no pregnancies among nulliparous users of Lea's Shield. Standardization of parity of this study population on those of the cap/diaphragm and sponge/diaphragm studies suggests that unadjusted pregnancy rates for this device would have been considerably lower (2.2 and 2.9 per 100 users of spermicide and non-spermicide, respectively) had the study been done using the populations of earlier studies. Since no directly comparative study has been done, these figures provide a tentative estimate of the relative efficacy of Lea's Shield compared with the sponge, cap, and diaphragm. There were no serious adverse experiences attributed to the use of Lea's Shield. Acceptability was very good. Seventy-five percent (75%) of women responded to an end-of-study questionnaire; 87% of these reported that they would recommend Lea's Shield to a friend. Lea's Shield is a new vaginal contraceptive that does not require clinician fitting. Pregnancy rates in this study compare favorably with other studies of barrier contraceptive methods including the cervical cap, diaphragm, and sponge, even though this study was done with greater rigor and with a greater percentage of parous women than previous barrier studies. Lea's Shield appears to be safe and very acceptable to study volunteers.

Comparison of urinary human follicle-stimulating hormone and human menopausal gonadotropins for ovarian stimulation in an in vitro fertilization program

This report compares the effects of human menopausal gonadotropin (hMG) and purified urinary human follicle-stimulating hormone (hFSH) protocols in patients with irreparable tubal disease as the sole indication for in vitro fertilization-embryo transfer (IVF-ET). The hFSH protocol was associated with significantly more uniform folliculogenesis and more effective steroidogenesis than the one using hMG. In addition, the hFSH protocol showed a trend toward more oocytes per laparoscopy and more embryos per transfer than the hMG group, although the difference was not statistically significant. More oocytes in the hMG group were classified as immature when compared with the hFSH group (P less than 0.05). Pregnancy rates in both groups were not significantly different. An allergic drug reaction that occurred in one patient on the hFSH protocol is the first such reaction reported with hFSH in the literature. The hFSH protocol is associated with a trend toward parameters that correlate with improved success rates in the IVF-ET program.

Breast milk distribution of theobromine from chocolate

Six nursing mothers ingested 113 gm of Hershey's milk chocolate containing 240 mg of theobromine. Samples of plasma, saliva, and breast milk were assayed for theobromine by high pressure liquid chromatography. Peak theobromine concentrations of 3.7 to 8.2 mg/l were found in all fluids at 2 to 3 hour after ingestion of chocolate. The disposition half-life of theobromine averaged 7.1 +/- 2.1 hours, body clearance was 65 +/- 20 ml/hour/kilogram, and the apparent volume of distribution was 0.62 +/- 0.13 l/lk. Theobromine is only slightly bound to plasma and milk proteins and concentrations in milk and saliva matched plasma data closely. The mean concentration ratios were 0.82 +/- 0.17 for milk/plasma and 0.92 +/- 0.17 for saliva/plasma. If a mother ate a 4-ounce chocolate bar every 6 hours and the infant nursed when the theobromine concentration in milk was at its peak, the infant could ingest about 10 mg of theobromine per day.