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Gori S, Frayle H, Pagan A, Soldà M, Romagnolo C, Insacco E, Laurino L, Matteucci M, Sordi G, Busato E, Zorzi M, Maggino T, Del Mistro A. Exploring conservative management for cervical intraepithelial neoplasia grade 2 in organised cervical cancer screening programmes: a multicentre study in Italy. Fam Med Community Health 2024; 12:e002595. [PMID: 38307701 PMCID: PMC10840026 DOI: 10.1136/fmch-2023-002595] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024] Open
Abstract
Cervical intraepithelial neoplasia grade 2 (CIN2) lesions may regress spontaneously, offering an alternative to immediate treatment, especially for women of childbearing age (15-45 years).We conducted a prospective multicentre study on conservative CIN2 management, with semiannual follow-up visits over 24 months, biomarkers' investigation and treatment for progression to CIN3+ or CIN2 persistence for more than 12 months. Here, we assess women's willingness to participate and adherence to the study protocol.The study was set in population-based organised cervical cancer screening.From April 2019 to October 2021, 640 CIN2 cases were diagnosed in women aged 25-64 participating in the screening programmes.According to our predefined inclusion and exclusion criteria, 228 (35.6%) women were not eligible; 93 (22.6%) of the 412 eligible refused, and 319 (77.4%) were enrolled. Refusal for personal reasons (ie, desire to become pregnant, anxiety, difficulty in complying with the study protocol) and external barriers (ie, residence elsewhere and language problems) accounted for 71% and 17%, respectively. Only 9% expressed a preference for treatment. The primary ineligibility factor was the upper age limit of 45 years. After enrolment, 12 (4%) women without evidence of progression requested treatment, 125 (39%) were lost to follow-up (mostly after 6-12 months) and 182 (57%) remained compliant. Remarkably, 40% of enrolees did not fully adhere to the protocol, whereas only 5% (20/412) of the eligible women desired treatment.Our study demonstrates a good acceptance of conservative management for CIN2 lesions by the women, supporting its implementation within cervical screening programmes.
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Affiliation(s)
- Silvia Gori
- Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - Helena Frayle
- Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | | | | | | | - Egle Insacco
- Obstetrics and Gynecology, Azienda Ospedale Università, Padova, Italy
| | | | - Mario Matteucci
- Obstetrics and Gynecology, Azienda Ospedale Università, Padova, Italy
| | | | | | - Manuel Zorzi
- Veneto Tumour Registry, Azienda Zero, Padova, Italy
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2
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Shanazarov N, Bariyeva G, Avdeyev A, Albayev R, Kisikova S, Zinchenko S, Galiev I. Evaluation of the effectiveness and safety of photodynamic therapy in the treatment of precancerous diseases of the cervix (neoplasia) associated with the human papillomavirus: A systematic review. Photodiagnosis Photodyn Ther 2024; 45:103925. [PMID: 38070631 DOI: 10.1016/j.pdpdt.2023.103925] [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: 08/01/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
This study provides an overview of the effectiveness and safety of PDT for the treatment of HPV-associated precancerous cervical conditions and contains recent findings from relevant research studies. A comprehensive literature search of MEDLINE/PubMed, Cochrane Central Library, and Google Scholar was conducted, including analytic epidemiological studies, and 11 papers were included. The narrative synthesis approach was used to summarize the results of the included studies. Studies were critically appraised using The Joanna Briggs Institute (JBI) tool for assessing the risk of bias. The results of the study demonstrate that CRR for HPV remission ranges from 66.7 % to 92.73 %, whereas for CIN1 it fluctuates from 57.1 % to 83.3 %. The frequency of recurrence of the disease ranged from 3.3 % to 8.9 % during the follow-up period of up to 2 years. Adverse events were observed in 8 (66 %) studies and the most common were cervical stenosis, abdominal pain, vaginal pain, and focal edema. Five types of topical and intravenous applications along with lasers of various wavelengths and intensities were mostly used. However, all studies demonstrated relatively similar results. According to the results, PDT has demonstrated favorable outcomes, but no impressive effect on the treatment of CIN. It should be emphasized, that the effectiveness of PDT for the treatment of HPV-associated CIN may vary depending on some variables, including the kind of PDT agent used, the dosage, duration and frequency of PDT administration, the severity and location of the lesions, and the host immunological response.
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Affiliation(s)
- Nasrulla Shanazarov
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan
| | - Gulzada Bariyeva
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan.
| | - Andrey Avdeyev
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan
| | - Rustam Albayev
- Medical Centre Hospital of President's Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan
| | - Saule Kisikova
- President's Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan
| | | | - Ilfat Galiev
- Kazan (Volga Region) Federal University, Kazan, Russia
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3
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Boisen M, Guido R. Emerging Treatment Options for Cervical Dysplasia and Early Cervical Cancer. Clin Obstet Gynecol 2023; 66:500-515. [PMID: 37650664 DOI: 10.1097/grf.0000000000000790] [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] [Indexed: 09/01/2023]
Abstract
DISCUSSION of treatment strategies for cervical cancer precursors, review of medical therapies and emerging therapeutics for treatment of cervical cancers, and updates on new approaches to treating early-stage cervical cancers.
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Affiliation(s)
- Michelle Boisen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
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Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) Consensus Statement on the Management of Vaginal Intraepithelial Neoplasia. J Low Genit Tract Dis 2023; 27:131-145. [PMID: 36951985 PMCID: PMC10026974 DOI: 10.1097/lgt.0000000000000732] [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] [Indexed: 03/24/2023]
Abstract
ABSTRACT The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
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Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, United Kingdom
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņ,š University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, IA
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Wilkin T, Chen H, Sahasrabuddhe V, Matining R, Mngqibisa R, Chinula L, Mbilizi Y, Magure T, Omoz-Oarhe AE, Rassool M, Riviere C, Bhosale R, Godbole S, Naranjo R, Coombs R, Michelow P, Godfrey C, Firnhaber C. A Randomized Clinical Trial of Human Papillomavirus Test-and-Treat as Compared to Cytology-Based Screening for Prevention of Cervical Cancer Among Women With Human Immunodeficiency Virus: AIDS Clinical Trials Group Protocol A5282. Clin Infect Dis 2022; 75:1280-1288. [PMID: 35294524 PMCID: PMC9555836 DOI: 10.1093/cid/ciac213] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cytology-based cervical cancer screening followed by confirmation and treatment of biopsy-proven high-grade squamous intraepithelial lesions (bHSIL) is difficult to implement in resource-constrained settings. We hypothesized that high-risk human papillomavirus (hrHPV) testing followed by immediate cryotherapy of women with hrHPV (HPV screen-and-treat) may improve outcomes. METHODS Randomized, open-label, phase 2, multinational clinical trial enrolling women with human immunodeficiency virus (HIV) age 18 or older with cervical hrHPV and having no cervical lesions or lesions appropriate for cryotherapy. Women were randomized to immediate cryotherapy (Arm A) or cytology-based screening (Arm B). For Arm A, cervical biopsies were obtained followed by cervical cryotherapy, and in Arm B, women with abnormal cytology underwent colposcopy followed by loop electroexcision procedure (LEEP) if bHSIL was detected. Women were followed through 30 months. The primary outcome was time to bHSIL detected from Month 6 through study completion. RESULTS In total, 288 women (145 in Arm A, 143 in Arm B) were randomized: median age 35 years, 84% on antiretroviral therapy, median CD4 501 cells/mm3. In Arm A, 39 (27%) of women had bHSIL at entry, and in Arm B, 88 (62%) had abnormal cytology, 22 (15%) were diagnosed with bHSIL, 12 (8%) underwent LEEP. In follow-up, 30 (21%) and 31 (22%) developed bHSIL; time to bHSIL was similar between arms (P=.94). The prevalence of hrHPV at Month 6 was similar between arms (61% and 70%, P=.13). CONCLUSIONS HPV test-and-treat was not associated with improved bHSIL outcomes as compared to cytology-based screening. More effective treatment options are required to improve outcomes from screen-and-treat programs. CLINICAL TRIALS REGISTRATION NCT01315363.
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Affiliation(s)
- Timothy Wilkin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Huichao Chen
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | | | - Roy Matining
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, Enhancing care Foundation, King Edward Hospital, Durban, South Africa
| | - Lameck Chinula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Tsitsi Magure
- University of Zimbabwe Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | | | - Mohammed Rassool
- Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Cynthia Riviere
- Clinical Research Department, Les Centres GHESKIO, Port-au-Prince, Haiti
| | - Rhamesh Bhosale
- Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sheela Godbole
- Division of Epidemiology, ICMR-National AIDS Research Unit, Pune, India
| | - Reena Naranjo
- Public Health & Scientific Research, Social & Scientific Systems, Inc, A DLH Holdings Company, Silver Spring, Maryland, USA
| | - Robert Coombs
- Departments of Laboratory Medicine & Pathology and Medicine, University of Washington, Seattle, Washington, USA
| | - Pamela Michelow
- National Health Laboratory Service, Johannesburg, South Africa
| | - Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, Washington D.C., USA
| | - Cynthia Firnhaber
- Division of Infectious Disease, Department of Medicine, University of Colorado Medical School, Aurora, Colorado, USA
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Egemen D, Perkins RB, Clarke MA, Guido R, Huh W, Saraiya M, Saslow D, Smith R, Unger ER, Garcia F, Wentzensen N, Cheung LC. Risk-Based Cervical Consensus Guidelines: Methods to Determine Management if Less Than 5 Years of Data Are Available. J Low Genit Tract Dis 2022; 26:195-201. [PMID: 35763610 PMCID: PMC9232276 DOI: 10.1097/lgt.0000000000000685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In the 2019 ASCCP Risk-Based Management Consensus Guidelines, clinical management decisions are based on immediate and 5-year cervical intraepithelial neoplasia (CIN) 3+ risk estimates. However, data for technologies other than human papillomavirus testing and cytology may be limited to clinical trials and observational studies of shorter duration than 5 years. To enable decisions about 1- or 3-year intervals, 3-year CIN 3+ risk equivalents to 5-year CIN 3+ risk thresholds were generated. MATERIALS AND METHODS We examined screening test result scenarios around the 5-year risk thresholds of 0.15% and 0.55% and calculated the average percent increase in CIN 3+ risk from 3 to 5 years. Using this average increase, we obtained estimates of corresponding risk thresholds at 3 years. We then validated whether use of the 3-year risk threshold would have resulted in equivalent management per the 2019 recommendations. RESULTS Around the 5-year CIN 3+ risk threshold of 0.55%, the average increase in risk from 3 to 5 years was 0.16%. Therefore, the equivalent threshold for 3-year risk was estimated as 0.39%. We found no difference in recommendations to return in 1 or 3 years using the 3-year or 5-year risk thresholds in 66 of the 67 scenarios (98.5%) in follow-up in 2019 guidelines. CONCLUSIONS In this methodological addendum, the Enduring Guidelines Committee adopted the use of the 0.39% 3-year CIN 3+ risk threshold as equivalent of the 0.55% 5-year CIN 3+ risk threshold for technologies with fewer than 5 years of follow-up data. This allows evidence-based guidance for surveillance intervals of 1 or 3 years for new technologies with limited longitudinal data.
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Affiliation(s)
- Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Rebecca B. Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA
| | - Megan A. Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Richard Guido
- Department of Obstetrics and Gynecology, Magee-Women's Hospital, Pittsburgh, PA
| | - Warner Huh
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Mona Saraiya
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Francisco Garcia
- Community and Health Services, Chief Medical Officer, Pima County, AZ
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Li C. Cheung
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
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7
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Tang J, Li M, Zhao C, Shen D, Liu L, Zhang X, Wei L. Therapeutic DNA Vaccines against HPV-Related Malignancies: Promising Leads from Clinical Trials. Viruses 2022; 14:v14020239. [PMID: 35215833 PMCID: PMC8874761 DOI: 10.3390/v14020239] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/19/2022] [Accepted: 01/22/2022] [Indexed: 01/27/2023] Open
Abstract
In 2014 and 2021, two nucleic-acid vaccine candidates named MAV E2 and VGX-3100 completed phase III clinical trials in Mexico and U.S., respectively, for patients with human papillomavirus (HPV)-related, high-grade squamous intraepithelial lesions (HSIL). These well-tolerated but still unlicensed vaccines encode distinct HPV antigens (E2 versus E6+E7) to elicit cell-mediated immune responses; their clinical efficacy, as measured by HSIL regression or cure, was modest when compared with placebo or surgery (conization), but both proved highly effective in clearing HPV infection, which should help further optimize strategies for enhancing vaccine immunogenicity, toward an ultimate goal of preventing malignancies in millions of patients who are living with persistent, oncogenic HPV infection but are not expected to benefit from current, prophylactic vaccines. The major roadblocks to a highly efficacious and practical product remain challenging and can be classified into five categories: (i) getting the vaccines into the right cells for efficient expression and presentation of HPV antigens (fusion proteins or epitopes); (ii) having adequate coverage of oncogenic HPV types, beyond the current focus on HPV-16 and -18; (iii) directing immune protection to various epithelial niches, especially anogenital mucosa and upper aerodigestive tract where HPV-transformed cells wreak havoc; (iv) establishing the time window and vaccination regimen, including dosage, interval and even combination therapy, for achieving maximum efficacy; and (v) validating therapeutic efficacy in patients with poor prognosis because of advanced, recurrent or non-resectable malignancies. Overall, the room for improvements is still large enough that continuing efforts for research and development will very likely extend into the next decade.
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Affiliation(s)
- Jianming Tang
- Aeonvital Biomedical Research Institute, Beijing 102208, China; (L.L.); (X.Z.)
- Correspondence: or
| | - Mingzhu Li
- Department of Gynecology and Obstetrics, Peking University People’s Hospital, Beijing 100033, China; (M.L.); (C.Z.); (D.S.); (L.W.)
| | - Chao Zhao
- Department of Gynecology and Obstetrics, Peking University People’s Hospital, Beijing 100033, China; (M.L.); (C.Z.); (D.S.); (L.W.)
| | - Danhua Shen
- Department of Gynecology and Obstetrics, Peking University People’s Hospital, Beijing 100033, China; (M.L.); (C.Z.); (D.S.); (L.W.)
| | - Lei Liu
- Aeonvital Biomedical Research Institute, Beijing 102208, China; (L.L.); (X.Z.)
| | - Xiujun Zhang
- Aeonvital Biomedical Research Institute, Beijing 102208, China; (L.L.); (X.Z.)
| | - Lihui Wei
- Department of Gynecology and Obstetrics, Peking University People’s Hospital, Beijing 100033, China; (M.L.); (C.Z.); (D.S.); (L.W.)
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8
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Yogeshkumar S, Anderson J, Lu E, Kenyi E, Mensa M, Thaler K, Antartani R, Donimath K, Patil B, Chikaraddi S, Bidri S, Biradar A, Gudadinni MR, Lokare L, Yenokyan G, Bellad MB, Goudar SS, Derman R, Revankar A, Patil H, Wani R, Kangle R, Chavan RY, Nagmoti MB, Kabadi YM, Reddy P, Vernekar S, Hipparagi S, Patil V, Dalal A. Safety and efficacy of the new CryoPop® cryotherapy device for cervical dysplasia in low- and middle-income countries: study protocol for a multicenter open-label non-inferiority clinical trial with historical controls. Trials 2021; 22:915. [PMID: 34903244 PMCID: PMC8666835 DOI: 10.1186/s13063-021-05802-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical cancer is the fourth most common cancer in the world, affecting mainly women residing in low- and middle-income countries. Progression from a pre-invasive phase to that of an invasive phase generally takes years and provides a window of opportunity to screen for and treat precancerous lesions. METHODS This study is being conducted at four sites in north Karnataka, India. Community sensitization activities have been organized in the study areas to create awareness among stakeholders, including elected representatives, physicians, health care workers, and potential participants. Organized community based as well as hospital-based screening is being conducted using visual inspection with acetic acid (VIA). Screen positive women are referred to respective study hospitals for colposcopy and directed biopsy. Participants with confirmed high-grade cervical dysplasia (high-grade squamous intraepithelial lesions or HSIL) who fit all other eligibility criteria will be recruited to the study and will receive cryotherapy using CryoPop®, an innovative new cryotherapy device. DISCUSSION There is a need to develop an inexpensive, simple, and effective cryotherapy device for use by frontline health care providers at locations where screening and timely treatment can be given, accelerating access to cervical cancer prevention services and minimizing loss to follow-up of women with precancerous lesions who need treatment. TRIAL REGISTRATION Clinical Trial Registry - India CTRI/2019/01/017289 ClinicalTrials.Gov number NCT04154644 . Registered on November 6, 2019.
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Affiliation(s)
- S. Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Jean Anderson
- Department of Obstetrics and Gynecology, Johns Hopkins University, School of Medicine, Baltimore, USA
| | - Enriquito Lu
- Jhpiego, an Affiliate of Johns Hopkins University, Baltimore, USA
| | - Edward Kenyi
- Jhpiego, an Affiliate of Johns Hopkins University, Baltimore, USA
| | - Margaret Mensa
- Jhpiego, an Affiliate of Johns Hopkins University, Baltimore, USA
| | - Katrina Thaler
- Department of Obstetrics and Gynecology, Johns Hopkins University, School of Medicine, Baltimore, USA
| | | | - Kasturi Donimath
- Karnataka Institute of Medical Sciences, Hubballi, Karnataka India
| | - Basavaraj Patil
- Karnataka Cancer Therapy & Research Institute, Hubballi, Karnataka India
| | - Santosh Chikaraddi
- Karnataka Cancer Therapy & Research Institute, Hubballi, Karnataka India
| | - Shailaja Bidri
- BLDE (Deemed to be University) Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapur, Karnataka India
| | - Aruna Biradar
- BLDE (Deemed to be University) Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapur, Karnataka India
| | - Muttappa R. Gudadinni
- BLDE (Deemed to be University) Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapur, Karnataka India
| | - Laxmikant Lokare
- Karnataka Institute of Medical Sciences, Hubballi, Karnataka India
| | - Gayane Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Mrutyunjaya B. Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Shivaprasad S. Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Richard Derman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, USA
| | - Amit Revankar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Hema Patil
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Ramadevi Wani
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Ranjit Kangle
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Ramesh Y. Chavan
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | - Mahantesh B. Nagmoti
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
| | | | | | - Sunita Vernekar
- Karnataka Institute of Medical Sciences, Hubballi, Karnataka India
| | - Surekha Hipparagi
- BLDE (Deemed to be University) Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapur, Karnataka India
| | - Vijayalaxmi Patil
- BLDE (Deemed to be University) Shri B. M. Patil Medical College Hospital and Research Centre, Vijayapur, Karnataka India
| | - Anita Dalal
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (KAHER), Belagavi, Karnataka India
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Hartman CA, Bragança JF, Gurgel MSC, Zeferino LC, Andrade LALA, Teixeira JC. Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome. PLoS One 2021; 16:e0253998. [PMID: 34283862 PMCID: PMC8291715 DOI: 10.1371/journal.pone.0253998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/18/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy. METHODS A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed. RESULTS Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7-92.3% for up to 24 mm cone height and 100% from 25 mm. CONCLUSION Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.
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Affiliation(s)
- Caio A. Hartman
- Department of Obstetrics and Gynecology, Gynecology Oncology Area, State University of Campinas (Unicamp), Sao Paulo, Brazil
| | - Joana F. Bragança
- Department of Obstetrics and Gynecology, Gynecology Oncology Area, State University of Campinas (Unicamp), Sao Paulo, Brazil
| | - Maria Salete C. Gurgel
- Department of Obstetrics and Gynecology, Gynecology Oncology Area, State University of Campinas (Unicamp), Sao Paulo, Brazil
| | - Luiz C. Zeferino
- Department of Obstetrics and Gynecology, Gynecology Oncology Area, State University of Campinas (Unicamp), Sao Paulo, Brazil
| | | | - Julio C. Teixeira
- Department of Obstetrics and Gynecology, Gynecology Oncology Area, State University of Campinas (Unicamp), Sao Paulo, Brazil
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Anderson KB, Frandsen AP, Sandal P, Søgaard-Andersen E. Follow-up After Loop Electrosurgical Excision of Cervical Intraepithelial Neoplasia: The Use of Combined Cytology and Human Papillomavirus Testing. J Low Genit Tract Dis 2021; 25:126-129. [PMID: 33660676 DOI: 10.1097/lgt.0000000000000600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aims of the study were to investigate how many women after 1 or 2 follow-up examinations, based on combined cervical cytology and human papillomavirus (HPV) testing, could finish posttreatment follow-up and continue with the general screening program and to determine the 5-year risk of recurrence in this group. METHODS This is a prospective observational study that includes women, who underwent loop electrosurgical excision procedure (LEEP) in the North Denmark Region, from January 1, 2012, to May 31, 2014. All included women had histologically verified diagnosis of high-grade cervical intraepithelial neoplasia (CIN 2+) or adenocarcinoma in situ (AIS) before LEEP and posttreatment follow-up with cervical cytology and HPV combination testing. Study period was until October 2019. RESULTS Totally, 563 women were included in the study. After finishing the posttreatment follow-up, 439 (78%) could continue to the general screening program and 362 of them had a screening during the study period. Six women (1.7%) had either cervical dysplasia and/or HPV infection in the cervical screening, and of these, 3 (0.8%) had high-grade dysplasia corresponding to CIN 2. None was diagnosed with CIN 3, AIS, or invasive carcinoma. One hundred twenty-one women (36%) chose to be screened sooner than recommended in the national guidelines. CONCLUSIONS Human papillomavirus and cytology combination test after LEEP allows women, irrespective of margin status, safely to continue with the general screening program after a short posttreatment follow-up period. Improved information is mandatory to reduce "opportunistic" screening after finishing posttreatment follow-up.
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Affiliation(s)
| | | | - Preben Sandal
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Erik Søgaard-Andersen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
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11
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Bradbury M, Centeno C, Pérez-Benavente A, Gil-Moreno A. Clinical Challenges in Managing Cervical Intraepithelial Neoplasia 2: A Report From a Cross-sectional Survey. J Low Genit Tract Dis 2021; 25:119-125. [PMID: 33631780 DOI: 10.1097/lgt.0000000000000594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of the study were to determine the management strategies offered to women with cervical intraepithelial neoplasia 2 (CIN 2) and the attitude of colposcopists toward its histological diagnosis and to identify the criteria used to select women for conservative management. METHODS Colposcopists working in Spain were invited to participate in an online questionnaire via the Spanish Gynecology and Colposcopy Societies. The survey included 42 questions covering the 3 objectives of the study. One hundred eighty-two colposcopists representing all autonomous regions in Spain responded. The response rate was 26.2%, considering the total number of members. RESULTS Most colposcopists offer conservative management in selected cases (153/182). The preferred follow-up interval is 6 months (65%), followed by 3-4 months (30%). Observation was considered no longer appropriate after 24 months (29.5%) and 12 months (26.3%), and 24.3% expressed that it depended on women's plan to conceive. During conservative management, 93.9% always perform a cytology, 62.7% human papillomavirus testing, 96.8% colposcopy, 47.9% cervical biopsy, and 28.1% endocervical curettage. Forty-five percent consider that CIN 2 merely represents a misclassified CIN 1 or CIN 3, whereas 46.2% think that CIN 2 lesions are unlikely to regress. Most respondents considered that age older than 40 years (81.3%), human papillomavirus 16 infection (62.1%), HIV infection (76.8%), positive p16 immunostaining (60.2%), a large lesion occupying more than 50% of the cervix (87%), endocervical involvement (91.6%), and previous treatment for CIN 2-3 (77%) are contraindications for conservative management. CONCLUSIONS Management of CIN 2 remains challenging for colposcopists, and a lack of consensus still exists in clinical practice. A better understanding of the natural history of CIN 2 and its clinical outcomes is still necessary to guide clinicians in its management.
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12
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Xiong Y, Cui L, Bian C, Zhao X, Wang X. Clearance of human papillomavirus infection in patients with cervical intraepithelial neoplasia: A systemic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23155. [PMID: 33181688 PMCID: PMC7668491 DOI: 10.1097/md.0000000000023155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There are currently no available standard drugs treating human papillomavirus (HPV) infection, especially for patients with low-grade cervical lesion. Several therapies are explored but the results are inconclusive. The objective of this study was to evaluate the efficacy of reported non-invasive treatments in patients with HPV infection and cervical lesions by meta-analysis. METHODS A comprehensive search of prospective and randomized studies published from April 2000 to April 2020 was conducted in electronic databases. The statistical analyses of the pooled risk ratios (RRs) and the corresponding 95% confidence intervals (95% CIs) were performed using the Revman 5.2 software. RESULTS Twelve articles including 12 randomized controlled studies and 1 prospective controlled randomized pilot study were enrolled. Therapeutic medications included biological and herbal regimen, interferon regimen and probiotics. The meta-analysis showed the experimental treatments had a statistically significant improvement in HPV clearance rate compared with the controls (RR = 0.71, 95% CI [0.63, 0.80], P < .00001); subgroup analyses stratified by regimen categories were consistent with results in the overall group. Treatment using biological and herbal regimen, interferon regimen or probiotics also resulted in a beneficial outcome in regression rate of cervical lesions compared with the controls (RR = 0.55, 95% CI [0.39, 0.79], P = .001). The trend was more favorable in the probiotics than that in the biological and herbal regimen (RR 0.48 vs 0.72). CONCLUSION Treatment of biological and herbal regimen, interferon regimen and probiotics benefit patients who have HPV infection and cervical lesions. Both the clearance of HPV and regression of cervical lesions are significant. More studies with less heterogeneity are needed to draw a concrete conclusion.
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13
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Bruno MT, Scalia G, Cassaro N, Costanzo M, Boemi S. Conservative management of CIN2 p16 positive lesions in women with multiple HPV infection. BMC Infect Dis 2020; 20:801. [PMID: 33121447 PMCID: PMC7597054 DOI: 10.1186/s12879-020-05530-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND According to the 2006 American Society for Colposcopy and Cervical Pathology guidelines, positive CIN2 p16 in women over the age of 25 should be managed with excisional treatment. However, excisional treatment is associated with physical, psychological and obstetric morbidity and can have a negative impact on sexual function. In our study we sought to identify a clear management strategy, addressing the impact of routine use of p16 immunohistochemistry in this population and identify appropriate criteria for patient selection with the aim of reducing over-treatment. METHOD We studied the medical records of 130 patients who had undergone laser therapy for CIN2. Each patient underwent colposcopy, biopsy and HPV test and were tested for p16 protein,. Patients were divided based on HPV infection into: single infections, multiple infections. All patients underwent ZTA laser therapy with follow-up (2-year follow-up). STATISTICAL ANALYSIS Contingency tables were created to evaluate the correlation between single, multiple and CIN2+ infections. Values with p < 0.05 were considered statistically significant. RESULTS Single infections had a histological regression of 61.8% (21/34) and a histological persistence rate of 35.3% (12/34), which was greater than the multiple infection rate. The common characteristic that the women with persistence and progression had was the dimension of the lesion and the genotype 16. Ten cases of histological persistence and the only case of progression had one lesion greater than three quarters of the cervix. CONCLUSIONS With the progress of our understanding of the natural history of infection from human papillomavirus and the increasing use of colposcopy, thanks to the addition of HPV genotyping and the technique of immunohistochemistry, conservative management of these lesions is now possible.
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Affiliation(s)
- Maria Teresa Bruno
- Department of General Surgery and Medical Surgery Specialties, Gynecological Clinic, University of Catania, Catania, Italy
| | - Guido Scalia
- Department of Biomedical and Biotechnological Sciences, Clinical Virology, University of Catania, Catania, Italy
| | | | - Maria Costanzo
- Department of Biomedical and Biotechnological Sciences, Clinical Virology, University of Catania, Catania, Italy
| | - Sara Boemi
- Department of General Surgery and Medical Surgery Specialties, Gynecological Clinic, University of Catania, Catania, Italy
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Affiliation(s)
- George F Sawaya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
- Center for Healthcare Value, University of California, San Francisco
| | - Robyn Lamar
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | - Rebecca B Perkins
- Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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15
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Yang Y, Zhang L, Qi R, Huo W, Li X, Wu X, Chen H, Gao XH. Treatment of high risk human papillomavirus infection in low grade cervical squamous intraepithelial lesion with mild local thermotherapy: Three case reports. Medicine (Baltimore) 2020; 99:e21005. [PMID: 32629719 PMCID: PMC7337530 DOI: 10.1097/md.0000000000021005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Mild local hyperthermia at 44°C has been proven efficacious in the treatment of cutaneous warts induced by human papillomavirus (HPV), while its effect on cervical intraepithelial neoplasia (CIN) caused by high risk type of HPVs has not been reported. PATIENT CONCERNS Three patients with low grade CIN and positive high risk HPV types (HPV 16, 31, 52, 56, 58) are reported in this study. DIAGNOSIS The diagnosis was based on identification of HPV types and abnormal cytological findings. INTERVENTIONS The 3 patients were treated with local hyperthermia from ceramic heating (surface temperature, 44°C) to cervix. The treatment was delivered once a day for 3 consecutive days, plus two similar treatments 10 ± 3 days later, with each session lasting 30 minutes. HPV and cytology test were performed 3 months thereafter. OUTCOMES All the 3 patients recovered to normal cytological findings. Two of the patients were negative for HPV, the remaining patient with pre-treatment HPV 56 and 58 positivity changed to HPV58 positive alone. CONCLUSION This pilot observation inspires that mild local hyperthermia be recommended as a new method in the treatment of CIN patients with persistent HPV infection, once validated by qualified RCT.
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Affiliation(s)
- Yang Yang
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
| | - Lan Zhang
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
| | - Ruiqun Qi
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
| | - Wei Huo
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
| | - Xiaodong Li
- Department of Dermatology, Central Hospital Affiliated to Shenyang Medical College
| | - Xin Wu
- Department of Obstetrics and Gynecology, The First Hospital of China Medical University, Shenyang, China
| | - Hongduo Chen
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
| | - Xing-Hua Gao
- Department of Dermatology, The First Hospital of China Medical University and Key Laboratory of Immunodermatology, Ministry of Health and Ministry of Education, National Joint Engineering Research Center for Theranostics of Immunological Skin Diseases, Liaoning
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Banerjee D, Mandal R, Mandal A, Ghosh I, Mittal S, Muwonge R, Lucas E, Basu P. A Prospective Randomized Trial to Compare Safety, Acceptability and Efficacy of Thermal Ablation and Cryotherapy in a Screen and Treat Setting. Asian Pac J Cancer Prev 2020; 21:1391-1398. [PMID: 32458647 PMCID: PMC7541890 DOI: 10.31557/apjcp.2020.21.5.1391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The prospective randomized study aimed to compare the safety, acceptability and efficacy of thermal ablation (TA) to that of cryotherapy in screen and treat setting. METHODS The participants were recruited prospectively in a community-based screening clinic in India. Women positive on visual inspection with acetic acid (VIA) test and/or Human Papillomavirus (HPV) test were assessed for eligibility for ablative treatment. Total 286 eligible women were randomized to receive either cryotherapy (N=150) or TA (N=136) performed by health workers. Colposcopy and cervical biopsy were performed on all, prior to treatment. Post-treatment follow-up was after one year with colposcopy and biopsy. RESULTS Both the treatment methods had high acceptability. Significantly higher proportion of women treated by cryotherapy reported pain compared to women treated by TA, though intensity was mild in vast majority of them. Approximately 30% of women in both arms had histologic abnormalities, mainly CIN 1, and among those who attended follow-up 74.1% and 81.0% didn't have any CIN after cryotherapy and TA respectively. CONCLUSION TA is as acceptable and safe as cryotherapy in screen and treat setting. TA has the logistic advantages for the low-resourced settings as the machines are more portable, do not require costly refrigerant gas and battery-driven models are available. The cure rates for CIN 1+ lesions in our study were comparable between cryotherapy and TA.
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Affiliation(s)
| | - Ranajit Mandal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Amit Mandal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Ishita Ghosh
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | - Srabani Mittal
- Chittaranjan National Cancer Institute, Kolkata, West Bengal, India.
| | | | - Eric Lucas
- International Agency for Research on Cancer, Lyon, France.
| | - Partha Basu
- International Agency for Research on Cancer, Lyon, France.
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Goldstein A, Goldstein LS, Lipson R, Bedell S, Wang J, Stamper SA, Brenner G, Goldstein GR, O'Keefe KD, O'Keefe SC, O'Keefe M, O'Keefe T, Goldstein AR, Zhao A. Assessing the feasibility of a rapid, high-volume cervical cancer screening programme using HPV self-sampling and digital colposcopy in rural regions of Yunnan, China. BMJ Open 2020; 10:e035153. [PMID: 32234744 PMCID: PMC7170644 DOI: 10.1136/bmjopen-2019-035153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Implementation of a novel, rapid, high-volume, see-and-treat cervical cancer screening programme using self-swab human papillomavirus (HPV) testing and digital colposcopy in underserved regions of Yunnan China. DESIGN 480-980 women per day self-swabbed for high-risk HPV (hrHPV+). Four careHPV machines (Qiagen) were run simultaneously to test the specimens. All hrHPV+ patients were contacted the same day and digital colposcopy was performed with the enhanced visual assessment system (MobileODT). Digital images were obtained, and all suspected lesions were biopsied and then treated. SETTING Rural and underserved areas of the Yunnan province, Kunming municipality. PARTICIPANTS 3600 women, mean age 50.2 years, who had never been screened for cervical cancer. The women were of the Yi, Hui, Dai and Han ethnicities. INTERVENTIONS Cryotherapy was performed on all lesions suspicious for cervical intraepithelial neoplasia (CIN) 1 and loop electrosurgical excision procedure was performed on all lesions suspicious for ≥CIN2. Endocervical curettage was performed if the transformation zone was not fully visualised. RESULTS 216 women (6%) were hrHPV+. 168 underwent same-day colposcopy (23 CIN1, 17≥CIN2). Digital colposcopy was able to identify 15 of 16 (93.8%)≥CIN2 lesions. CONCLUSIONS This study illustrates a high-volume, rapid and practical strategy that can be used to screen and treat an ethnically diverse group of Chinese women. First, HPV self-sampling allows large numbers of women to be screened rapidly and relatively inexpensively. Only hrHPV+ women will then require further evaluation. Digital colposcopy is then performed on hrHPV+ women with a portable digital colposcope. The high-resolution images obtained can facilitate appropriate same-day treatment as they are able to accurately distinguish between CIN1 and ≥CIN2 lesions.
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Affiliation(s)
- Andrew Goldstein
- Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- The Center for Vulvovaginal Disorders, Washington, DC, USA
| | | | - Roberta Lipson
- Beijing United Family Hospitals and Clinics, Beijing, China
| | - Sarah Bedell
- The Center for Vulvovaginal Disorders, Washington, DC, USA
| | - Jue Wang
- Beijing United Family Hospitals and Clinics, Beijing, China
| | - Sarah A Stamper
- Department of Psychological and Brain Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | - McKenna O'Keefe
- Engineering, University of California Berkeley, Berkeley, California, USA
| | | | | | - Anna Zhao
- Beijing United Family Hospitals and Clinics, Beijing, China
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18
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Kalliala I, Athanasiou A, Veroniki AA, Salanti G, Efthimiou O, Raftis N, Bowden S, Paraskevaidi M, Aro K, Arbyn M, Bennett P, Nieminen P, Paraskevaidis E, Kyrgiou M. Incidence and mortality from cervical cancer and other malignancies after treatment of cervical intraepithelial neoplasia: a systematic review and meta-analysis of the literature. Ann Oncol 2020; 31:213-227. [PMID: 31959338 PMCID: PMC7479506 DOI: 10.1016/j.annonc.2019.11.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/27/2019] [Accepted: 11/04/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although local treatments for cervical intraepithelial neoplasia (CIN) are highly effective, it has been reported that treated women remain at increased risk of cervical and other cancers. Our aim is to explore the risk of developing or dying from cervical cancer and other human papillomavirus (HPV)- and non-HPV-related malignancies after CIN treatment and infer its magnitude compared with the general population. MATERIALS AND METHODS Design: Systematic review and meta-analysis. Eligibility criteria: Studies with registry-based follow-up reporting cancer incidence or mortality after CIN treatment. DATA SYNTHESIS Summary effects were estimated using random-effects models. OUTCOMES Incidence rate of cervical cancer among women treated for CIN (per 100 000 woman-years). Relative risk (RR) of cervical cancer, other HPV-related anogenital tract cancer (vagina, vulva, anus), any cancer, and mortality, for women treated for CIN versus the general population. RESULTS Twenty-seven studies were eligible. The incidence rate for cervical cancer after CIN treatment was 39 per 100 000 woman-years (95% confidence interval 22-69). The RR of cervical cancer was elevated compared with the general population (3.30, 2.57-4.24; P < 0.001). The RR was higher for women more than 50 years old and remained elevated for at least 20 years after treatment. The RR of vaginal (10.84, 5.58-21.10; P < 0.001), vulvar (3.34, 2.39-4.67; P < 0.001), and anal cancer (5.11, 2.73-9.55; P < 0.001) was also higher. Mortality from cervical/vaginal cancer was elevated, but our estimate was more uncertain (RR 5.04, 0.69-36.94; P = 0.073). CONCLUSIONS Women treated for CIN have a considerably higher risk to be later diagnosed with cervical and other HPV-related cancers compared with the general population. The higher risk of cervical cancer lasts for at least 20 years after treatment and is higher for women more than 50 years of age. Prolonged follow-up beyond the last screening round may be warranted for previously treated women.
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Affiliation(s)
- I Kalliala
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A Athanasiou
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A A Veroniki
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - G Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - O Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - N Raftis
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | - S Bowden
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - M Paraskevaidi
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - K Aro
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
| | - P Bennett
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - P Nieminen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - E Paraskevaidis
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | - M Kyrgiou
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK; Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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19
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Pinder LF, Parham GP, Basu P, Muwonge R, Lucas E, Nyambe N, Sauvaget C, Mwanahamuntu MH, Sankaranarayanan R, Prendiville W. Thermal ablation versus cryotherapy or loop excision to treat women positive for cervical precancer on visual inspection with acetic acid test: pilot phase of a randomised controlled trial. Lancet Oncol 2020; 21:175-184. [PMID: 31734069 PMCID: PMC6946855 DOI: 10.1016/s1470-2045(19)30635-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cryotherapy is standard practice for treating patients with cervical precancer in see-and-treat programmes in low-income and middle-income countries (LMICs). Because of logistical difficulties with cryotherapy (eg, the necessity, costs, and supply chain difficulties of refrigerant gas; equipment failure; and treatment duration >10 min), a battery-operated thermal ablator that is lightweight and portable has been developed. We aimed to compare thermal ablation using the new device with cryotherapy. METHODS We report the pilot phase of a randomised controlled trial in routine screen-and-treat clinics providing cervical screening using visual inspection with acetic acid (VIA) in Lusaka, Zambia. We recruited non-pregnant women, aged 25 years or older, who were eligible for ablative therapy. We randomly assigned participants (1:1:1) to thermal ablation, cryotherapy, or large loop excision of the transformation zone (LLETZ), using computer-generated allocation. The randomisation was concealed but the nurses providing treatment and the participants were unmasked. Thermal ablation was achieved using the Liger thermal ablator (using 1-5 overlapping applications of the probe heated to 100°C, each application lasting for 40 s), cryotherapy was carried out using the double-freeze technique (freeze for 3 min, thaw for 5 min, and freeze again for 3 min), and LLETZ (using a large loop driven by an electro-surgical unit to excise the transformation zone) was done under local anaesthesia. The primary endpoint was treatment success, defined as either human papillomavirus (HPV) type-specific clearance among participants who were positive for the same HPV type at baseline, or a negative VIA test at 6-month follow-up, if the baseline HPV test was negative. Per protocol analyses were done. Enrolment for the full trial is ongoing. Here, we present findings from a prespecified pilot phase of the full trial. The final analysis of the full trial will assess non-inferiority of the groups for the primary efficacy endpoint. The study is registered with ClinicalTrials.gov, number NCT02956239. FINDINGS Between Aug 2, 2017, and Jan 15, 2019, 750 participants were randomly assigned (250 per group). 206 (84%) participants in the cryotherapy group, 197 (81%) in the thermal ablation group, and 204 (84%) in the LLETZ group attended the 6-month follow-up examination. Treatment success was reported in 120 (60%) of 200 participants in the cryotherapy group, 123 (64%) of 192 in the thermal ablation group, and 134 (67%) of 199 in the LLETZ group (p=0·31). Few participants complained of moderate to severe pain in any group immediately after the procedure (six [2%] of 250 in the cryotherapy group, four [2%] of 250 in the thermal ablation group, and five [2%] of 250 in the LLETZ group) and 2 weeks after the procedure (one [<1%] of 241 in the cryotherapy group, none of 242 in the thermal ablation group, and two [<1%] of 237 in the LLETZ group). None of the participants reported any complication requiring medical consultation or admission to hospital. INTERPRETATION Results from this pilot study preliminarily suggest that thermal ablation has similar treatment success to cryotherapy, without the practical disadvantages of providing cryotherapy in an LMIC. However, the study was not powered to establish the similarity between the techniques, and results from the ongoing randomised controlled trial are need to confirm these results. FUNDING US National Institutes of Health.
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Affiliation(s)
- Leeya F Pinder
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA; Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Groesbeck P Parham
- Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France.
| | - Richard Muwonge
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | - Eric Lucas
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | | | - Catherine Sauvaget
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
| | - Mulindi H Mwanahamuntu
- Department of Obstetrics and Gynecology, Women and Newborn Hospital, University of Zambia, Lusaka, Zambia
| | - Rengaswamy Sankaranarayanan
- Research Triangle Institute, International-India, Commercial Tower, Pullman Hotel Aerocity, New Delhi, India
| | - Walter Prendiville
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, WHO, Lyon, France
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20
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Freijomil-Vázquez C, Gastaldo D, Coronado C, Movilla-Fernández MJ. When risk becomes illness: The personal and social consequences of cervical intraepithelial neoplasia medical surveillance. PLoS One 2019; 14:e0226261. [PMID: 31841543 PMCID: PMC6913976 DOI: 10.1371/journal.pone.0226261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/23/2019] [Indexed: 11/19/2022] Open
Abstract
Background After the early detection of cervical intraepithelial neoplasia (CIN), medical surveillance of the precancerous lesions is carried out to control risk factors to avoid the development of cervical cancer. Objective To explore the effects of medical surveillance on the personal and social lives of women undergoing CIN follow-up and treatment. Methodology A generic qualitative study using a poststructuralist perspective of risk management was carried out in a gynecology clinic in a public hospital of the Galician Health Care System (Spain). Participants were selected through purposive sampling. The sample consisted of 21 women with a confirmed diagnosis of CIN. Semistructured interviews were recorded and transcribed, and a thematic analysis was carried out, including researcher triangulation to verify the results of the analysis. Findings Two main themes emerged from the participants’ experiences: CIN medical surveillance encounters and risk management strategies are shaped by the biomedical discourse, and the effects of “risk treatment” for patients include (a) profound changes expected of patients, (b) increased patient risk management, and (c) resistance to risk management. While doctors’ surveillance aimed to prevent the development of cervical cancer, women felt they were sick because they had to follow strict recommendations over an unspecified period of time and live with the possibility of a life-threatening disease. Clinical risk management resulted in the medicalization of women’s personal and social lives and produced great uncertainty. Conclusions This study is the first to conceptualize CIN medical surveillance as an illness experience for patients. It also problematizes the effects of preventative practices in women’s lives. Patients deal with great uncertainty, as CIN medical surveillance performed by gynecologists simultaneously trivializes the changes expected of patients and underestimates the effects of medical recommendations on patients’ personal wellbeing and social relations.
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Affiliation(s)
- Carla Freijomil-Vázquez
- Facultade de Enfermaría e Podoloxía, Universidade da Coruña, Ferrol, Spain
- Laboratorio de Investigación Cualitativa en Ciencias da Saúde (CCSS), Grupo de Investigación Cardiovascular (GRINCAR), Universidade da Coruña, Ferrol, Spain
- * E-mail:
| | - Denise Gastaldo
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Centre for Critical Qualitative Health Research, University of Toronto, Toronto, Canada
| | - Carmen Coronado
- Facultade de Enfermaría e Podoloxía, Universidade da Coruña, Ferrol, Spain
- Laboratorio de Investigación Cualitativa en Ciencias da Saúde (CCSS), Grupo de Investigación Cardiovascular (GRINCAR), Universidade da Coruña, Ferrol, Spain
| | - María-Jesús Movilla-Fernández
- Facultade de Enfermaría e Podoloxía, Universidade da Coruña, Ferrol, Spain
- Laboratorio de Investigación Cualitativa en Ciencias da Saúde (CCSS), Grupo de Investigación Cardiovascular (GRINCAR), Universidade da Coruña, Ferrol, Spain
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Martinelli M, Musumeci R, Sechi I, Sotgiu G, Piana A, Perdoni F, Sina F, Fruscio R, Landoni F, Cocuzza CE. Prevalence of Human Papillomavirus (HPV) and Other Sexually Transmitted Infections (STIs) among Italian Women Referred for a Colposcopy. Int J Environ Res Public Health 2019; 16:ijerph16245000. [PMID: 31818033 PMCID: PMC6950209 DOI: 10.3390/ijerph16245000] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 11/27/2019] [Accepted: 11/29/2019] [Indexed: 01/03/2023]
Abstract
Sexually transmitted infections (STIs) represent a major cause of morbidity in women and men worldwide. Human Papillomavirus (HPV) infections are among the most prevalent STIs and persistent infections with high-risk HPV (hrHPV) genotypes can cause cervical dysplasia and invasive cervical cancer. The association of other STIs with HPV cervical infection and/or dysplasia has however not yet been fully elucidated. The aim of this study was to assess the prevalence of HPV and other STIs among women presenting with an abnormal cervical cytology. Cervical infections with 28 HPV genotypes and seven other sexually transmitted pathogens were evaluated in 177 women referred for a colposcopy after an abnormal Pap smear. Positivity for at least one hrHPV genotype was shown in 87% of women; HPV 16 was the most prevalent (25.0%), followed by HPV 31 and HPV 51. The overall positivity for other STIs was 49.2%, with Ureaplasma parvum being the most prevalent microrganism (39.0%). Co-infections between hrHPV and other STIs were demonstrated in 17.5% of women; no significant association was demonstrated between multiple infections and the colposcopy findings. This study provides new epidemiological data on the prevalence of cervical infections associated with HPV and seven other common sexually transmitted pathogens in a population of women presenting with an abnormal cervical cytology.
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Affiliation(s)
- Marianna Martinelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
| | - Rosario Musumeci
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
| | - Illari Sechi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (I.S.); (G.S.); (A.P.)
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (I.S.); (G.S.); (A.P.)
| | - Andrea Piana
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (I.S.); (G.S.); (A.P.)
| | - Federica Perdoni
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
| | - Federica Sina
- ASST Monza, San Gerardo Hospital, 20900 Monza, Italy;
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
- ASST Monza, San Gerardo Hospital, 20900 Monza, Italy;
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
- ASST Monza, San Gerardo Hospital, 20900 Monza, Italy;
| | - Clementina E. Cocuzza
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza, Italy; (M.M.); (R.M.); (F.P.); (R.F.); (F.L.)
- Correspondence:
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22
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Pliszkiewicz M, Brzuchalski MA, Pliszkiewicz M, Siekierski BP. [CO2 laser ablation of cervical endometrioid lesions - treatment efficacy evaluation]. Pol Merkur Lekarski 2019; 47:60-64. [PMID: 31473753] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED Endometriosis affects 10-15% of the female population of childbearing potential. Endometrioid lesions of the cervical surface are a rare manifestation of the disease. There are various complaints related to this particular form of endometriosis, making the diagnosis challenging. Treatment also raises problems, as widely available and used therapeutic methods often prove to be ineffective. AIM The aim of the study was to evaluate the efficacy of CO2 laser beam ablation in a group of patients with cervical endometriosis lesions. MATERIALS AND METHODS This paper presents a summary of cervical endometriosis treatment efficacy in a group of 15 patients who have undergone CO2 laser ablation between May 2016 and April 2019. The majority of patients have already been treated for cervical endometriosis, using cryotherapy, electrocoagulation, curettage and loop electrosurgical excision procedure (LEEP). All patients, following preliminary colposcopy verification and exclusion of malignancies, have undergone CO2 laser ablation of endometrioid cervical lesions. A visual evaluation of the cervix was performed before treatment, directly after the procedure, as well as 4-6 weeks after the procedure, and subsequently every 6-8 months. RESULTS This paper presents a summary of cervical endometriosis treatment efficacy in a group of 15 patients who have undergone CO2 laser ablation between May 2016 and April 2019. The majority of patients have already been treated for cervical endometriosis, using cryotherapy, electrocoagulation, curettage and loop electrosurgical excision procedure (LEEP). All patients, following preliminary colposcopy verification and exclusion of malignancies, have undergone CO2 laser ablation of endometrioid cervical lesions. A visual evaluation of the cervix was performed before treatment, directly after the procedure, as well as 4-6 weeks after the procedure, and subsequently every 6-8 months. CONCLUSIONS Cervical endometriosis is a rare manifestation of the diseases, with variable symptoms. It can become a diagnostic challenge, as endometrioid lesions may be confused with cervical malignancies, as well as a therapeutic one, as many of the methods employed prove unsuccessful. Laser ablation of endometrioid cervical lesions seen to be a minimally invasive, safe and effective treatment method that can be offered in an outpatient setting.
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Affiliation(s)
| | | | | | - B Paweł Siekierski
- Medicover Hospital, Department of Obstetric and Gynecology, Warsaw, Poland
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Gonçalves CA, Lopes-Júnior LC, Nampo FK, Zilly A, Mayer PCM, Pereira-da-Silva G. Safety, efficacy and immunogenicity of therapeutic vaccines in the treatment of patients with high-grade cervical intraepithelial neoplasia associated with human papillomavirus: a systematic review protocol. BMJ Open 2019; 9:e026975. [PMID: 31320349 PMCID: PMC6661674 DOI: 10.1136/bmjopen-2018-026975] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 05/06/2019] [Accepted: 06/14/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Eighty per cent of the sexually active population will get human papillomavirus (HPV) infection, which is the most prevalent sexually transmitted disease worldwide. Persistence of high-grade HPV infection may evolve to a cervical intraepithelial neoplasia (CIN), and these lesions may be precursors of cervical cancer. However, this progression can be prevented by the administration of therapeutic vaccines which use the main oncoproteins responsible for cancer development in an attempt to trigger a more specific and effective immunological response against this disorder. We aim to evaluate the safety, efficacy and immunogenicity of therapeutic vaccines in the treatment of patients with high-grade CIN 2/3 associated with HPV. METHODS AND ANALYSIS A systematic review of clinical trials will be undertaken. Medline, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, Web of Science, Latin American and Caribbean Health Sciences Literature, Scientific Electronic Library Online and Scopus will be searched, with no restriction regarding publication date. Primary outcomes will include measures related to safety, efficacy and the immunogenicity of the therapeutic vaccines used in these patients. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological appraisal of the studies will be assessed by the Cochrane Risk-of-Bias Tool for randomised controlled trials, and the quality evidence of the risk of bias in single studies will be evaluated by Grading of Recommendations Assessment, Development and Evaluation. A narrative synthesis will be done for all included studies. Outcomes will be analysed according to the subgroups of HPV type, CIN grade, route of vaccine administration and vaccine type. Also, if sufficient data are available, a meta-analysis will be conducted. The effect sizes will be generated using Hedges' g score for both fixed and random effect models. I 2 statistics will be used to assess heterogeneity and identify their potential sources. ETHICS AND DISSEMINATION Ethical approval is not required as primary data will not be collected. Findings will be disseminated widely via peer-reviewed publication and in different media, for example, conferences, congresses or symposia. PROSPERO REGISTRATION NUMBER CRD42017077428.
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Affiliation(s)
- Caroline Amélia Gonçalves
- Department of Maternal-Infant and Public Health Nursing, University of São Paulo (USP) at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Luís Carlos Lopes-Júnior
- Nursing Department, Health Sciences Center, Federal University of Espírito Santo (UFES), Vitoria, Espírito Santo, Brazil
| | - Fernando Kenji Nampo
- Latin-American Institute of Life and Natural Sciences, Federal University of Latin-American Integration (UNILA), Foz do Iguaçu, Paraná, Brazil
| | - Adriana Zilly
- Programa de Pós-Graduação em Saúde Pública em Região de Fronteira, State University of West of Paraná (UNIOESTE), Foz do Iguaçu, Paraná, Brazil
| | | | - Gabriela Pereira-da-Silva
- Department of Maternal-Infant and Public Health Nursing, University of São Paulo (USP) at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
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Toyoda S, Kawaguchi R, Kobayashi H. Clinicopathological Characteristics of Atypical Glandular Cells Determined by Cervical Cytology in Japan: Survey of Gynecologic Oncology Data from the Obstetrical Gynecological Society of Kinki District, Japan. Acta Cytol 2019; 63:361-370. [PMID: 31048578 DOI: 10.1159/000498977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 01/21/2019] [Accepted: 02/13/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The purpose of this study was to clarify the clinicopathological characteristics of, and the clinical approach used to identify, atypical glandular cells (AGCs) in Japan based on cervical cytology screening. OBJECTIVES This study included 1,254 patients with AGCs who underwent cervical cytology. METHOD Data from patients with AGCs were used to examine the practical management of AGCs and the histological results. RESULTS The incidence of AGCs was 0.20% (1,254/614,791). The 1,254 AGC cases included 859 endocervical cells not otherwise specified (NOS), 3 glandular cells NOS, 91 endocervical cells favor neoplasia (FN), and 301 atypical endometrial cells (AEMCs). Among the 1,254 AGC patients, the histological diagnosis was benign in 666 (53.1%), cervical intraepithelial neoplasia (CIN) 1 in 60 (4.8%), CIN2 in 31 (2.5%), CIN3 in 52 (4.1%), squamous cell carcinoma in 19 (1.5%), adenocarcinoma in situ in 39 (3.1%), cervical adenocarcinoma in 106 (8.5%), endometrial carcinoma in 209 (16.7%), ovarian cancer in 26 (2.1%), other malignancy in 4 (0.3%), and other under follow-up in 42 (3.3%). When the 1,254 AGC patients were divided into three medical intervention degrees according to histology, AGC-NOS, AGC-FN, and AEMC required no medical intervention in 78.7, 13.2, and 25.9% (678, 12, and 78) of the patients, cervical cone resection in 13.0, 9.9, and 0.3% (112, 9, and 1) of the patients, and radical laparotomy for invasive cancer in 8.3, 76.9, and 73.8% (72, 70, and 222) of the patients, respectively. CONCLUSIONS Our histological results supported the medical interventions applied for AGC diagnosis and treatment. AGC cases require careful histological evaluation.
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Affiliation(s)
- Shinji Toyoda
- Department of Obstetrics and Gynecology, Nara Prefecture General Medical Center, Nara, Japan,
| | - Ryuji Kawaguchi
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Japan
| | - Hiroshi Kobayashi
- Department of Obstetrics and Gynecology, Nara Medical University, Kashihara, Japan
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Lince-Deroche N, van Rensburg C, Roseleur J, Sanusi B, Phiri J, Michelow P, Smith JS, Firnhaber C. Costs and cost-effectiveness of LEEP versus cryotherapy for treating cervical dysplasia among HIV-positive women in Johannesburg, South Africa. PLoS One 2018; 13:e0203921. [PMID: 30308014 PMCID: PMC6181291 DOI: 10.1371/journal.pone.0203921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
Background Cervical cancer incidence is significant in countries, such as South Africa, with high burdens of both HIV and human papillomavirus (HPV). Cervical cancer is largely preventable if dysplasia is diagnosed and treated early, but there is debate regarding the best approaches for screening and treatment, especially for low-resource settings. Currently South Africa provides Pap smears followed by colposcopic biopsy and LEEP if needed in its public health facilities. We estimated the costs and cost-effectiveness of two approaches for treating cervical intraepithelial neoplasia grade 2 or higher (CIN2+) among HIV-infected women, most of whom were taking antiretroviral treatment, at a public HIV treatment facility in Johannesburg, South Africa. Methods Method effectiveness was derived from an intention-to-treat analysis of data gathered in a clinical trial completed previously at the study facility. In the trial, women who were diagnosed with CIN2+ and eligible for cryotherapy were randomized to cryotherapy or LEEP. If women were CIN2+ at six months as determined via Pap smear and colposcopic biopsy, all women—regardless of their original treatment assignment—received LEEP. “Cure” was then defined as the absence of disease at 12 months based on Pap smear and colposcopic biopsy. Health service costs were estimated using micro-costing between June 2013 and April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered, and results from an as-treated analysis were considered in sensitivity analysis. Results In total, 166 women with CIN2+ were enrolled (86 had LEEP; 80 had cryotherapy). At 12 months, cumulative loss to follow-up was 12.8% (11/86) for the LEEP group and 13.8% (11/80) for cryotherapy. Based on the unadjusted intention-to-treat analysis conducted for this economic evaluation, there was no significant difference in efficacy. At 12 months, 83.8% (95% CI 73.8–91.1) of women with CIN2+ at baseline and randomized to cryotherapy were free of CIN2+ disease. In contrast, 76.7% (95% CI 66.4–85.2) of women assigned to LEEP were free from disease. On average, women initially treated with cryotherapy were less costly per patient randomized at US$ 118.00 (113.91–122.10), and per case “cured” at US$ 140.90 (136.01–145.79). Women in the LEEP group cost US$ 162.56 (157.90–167.22) per patient randomized and US$ 205.59 (199.70–211.49) per case cured. In the as-treated analysis, which was based on trial data, LEEP was more efficacious than cryotherapy; however, the difference was not significant. Cryotherapy remained more cost-effective than LEEP in all sensitivity and scenario analyses. Conclusions For this cost-effectiveness analysis, using an intention-to-treat approach and taking into consideration uncertainty in the clinical and cost outcomes, a strategy involving cryotherapy plus LEEP if needed at six months was dominant to LEEP plus LEEP again at six months if needed for retreatment. However, compared to other studies comparing LEEP and cryotherapy, the efficacy results were low in both treatment groups–possibly due to the HIV-positivity of the participants. Further research is needed, but at present choosing the “right” treatment option may be less important than ensuring access to treatment and providing careful monitoring of treatment outcomes.
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Affiliation(s)
- Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Craig van Rensburg
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jaqueline Roseleur
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Busola Sanusi
- Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Jane Phiri
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pam Michelow
- Cytology Unit, National Health Laboratory Service and Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer S. Smith
- Gillings School of Public Health, University of North Carolina, Chapel Hill, NC, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States of America
| | - Cindy Firnhaber
- Right to Care, Johannesburg, South Africa
- Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Heinzler J, Brucker J, Bruckner T, Dinkic C, Hoffmann J, Dornhöfer N, Seitz S, Sohn C, Rom J, Schott TC, Schott S. Impact of a cervical dysplasia and its treatment on quality of life and sexual function. Arch Gynecol Obstet 2018; 298:737-745. [PMID: 30076544 DOI: 10.1007/s00404-018-4853-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 05/27/2018] [Accepted: 07/25/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE In this case-control study, the impact on quality of life and sexual function in women with cervical dysplasia and conization will be evaluated, in order to address coping with such a premalignant lesion and to improve strategies for salutogenesis. METHODS This multicenter case-control study evaluates women at special dysplasia outpatient clinic (T1) as well as 3 (T2) and 6 (T3) months after the diagnosis of a dysplasia. The women were subgrouped upon dysplasia only (S2) or dysplasia with conization (S1). Sexual function as well as cervix-related and general quality of life was assessed using validated instruments (FSFI-d, EORTC-QLQ-CX24, SF-36). RESULTS Women with dysplasia had a lower sexual functioning than controls (FSFI: S1: 23.8 ± 9.7 (p < 0.003); S2: 25.3 ± 7.5 (p < 0.03); K: 29.1 ± 4.5) as well as a lower physical component score (SF-36: S1: 51.3 ± 8.6 (p < 0.02); S2: 51.7 ± 7.8 (p < 0.05); K: 54.2 ± 6.6) and had a significantly reduced body image (EORTC-QLQ-CX24: S1: 75.7 (p < 0.001); S2: 76.5 (p < 0.001), K:89.2). Sexual functioning was not affected by conization in the observational period over 6 months; however, sexual worry was impacted. Over temporal progression women who underwent conization worried more. Regression analysis revealed a cervical dysplasia to impact sexual function. CONCLUSION Data suggest that women with the diagnosis of a cervical dysplasia are impaired in their sexual function as well as general and cervix-related quality of life, mostly independent of conization or further observation. To improve salutogenesis in the long run, the communication on dysplasia and its treatment strategy at the beginning, as well as part of aftercare, or psychosomatic intervention, might be treatment options for women at risk.
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Affiliation(s)
- Judith Heinzler
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany
| | - Janina Brucker
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany
| | - Thomas Bruckner
- Institut für Medizinische Biometrie Und Informatik, Universitätsklinik Heidelberg, Heidelberg, Germany
| | - Christine Dinkic
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany
| | | | | | - Stephan Seitz
- Caritas-Krankenhaus St. Josef Regensburg, Regensburg, Germany
| | - Christof Sohn
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany
| | - Joachim Rom
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany
| | - Timm C Schott
- Poliklinik für Kieferorthopädie, Universitätsklinik Tübingen, Tübingen, Germany
| | - Sarah Schott
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, Germany.
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Bryder L. Primum non nocere: first do no harm. N Z Med J 2018; 131:81-83. [PMID: 29771906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Linda Bryder
- History, School of Humanities, University of Auckland, Auckland
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Abstract
Aims and Background An increasing incidence of high-grade squamous intraepithelial lesion (HSIL) has been observed among young women. Consequently, an increased number of cases are being discovered during pregnancy. We analyzed the clinical and therapeutic management of HSIL during pregnancy. Methods A retrospective study was conducted from 1979 to 1998, and 58 registries of women with a cytological or histological diagnosis of HSIL during the pregnant-puerperal period were reviewed. Information obtained from medical records included age, gestational age at diagnosis, parity, age of first intercourse, number of sexual partners before pregnancy, tobacco use, cytologic and colposcopic findings, route of delivery, postpartum follow-up, and treatment. This information was compared with a non-pregnant control group with HSIL. Results The average age of pregnant women with HSIL was 27.9 ± 5.2 years. The cytologic or histologic diagnosis of HSIL was made in the first trimester in 12 (20.7%) women and in the second trimester in 30 (51.7%) women. Average parity was 2.8 ± 2 deliveries. Age of first intercourse ranged from 13 to 29 years (16.1 ± 3.3). Thirty-two women (55.1%) had more than one sexual partner before pregnancy. Thirty-seven (63.8%) refereed tobacco use. According to the aforementioned aspects, no statistical difference was found in relation to control, except to cervical ectopia, which was more frequent in pregnant women (56.9% versus 42.6%). From the total of 58 pregnant women with cytologic or biopsy HSIL diagnosis, 53 had HSIL diagnosis made on cervical biopsy directed by colposcopy performed during the pregnancy; 44 (83%) of them were submitted to conservative management. HSIL was diagnosed by cervical biopsy in postpartum evaluation in 76% pregnant women with vaginal delivery and 78.6% women who underwent cesarean section. Conclusions A conservative management of HSIL in pregnancy is proposed, with colposcopic evaluation during gestation and postpartum, regardless of route of delivery.
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Righolt CH, Pabla G, Mahmud SM. The Direct Medical Costs of Diseases Associated with Human Papillomavirus Infection in Manitoba, Canada. Appl Health Econ Health Policy 2018; 16:195-205. [PMID: 29299769 DOI: 10.1007/s40258-017-0367-1] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The total direct cost of screening and treating all human papillomavirus-related diseases (HPV-RD) has not been measured in a single study. Accurate cost estimates are needed to inform decisions on intervention priorities and evaluate the cost-effectiveness of existing programs. We used province-wide clinical, administrative, and accounting databases to measure direct medical costs of HPV infection in Manitoba (Canada). METHODS All persons 9 years or older with health insurance coverage in Manitoba between April 2000 and March 2015 were eligible. We identified all persons with an incident HPV-RD and aggregated all medical costs (in 2014 Canadian dollars) related to that condition, including prescription drugs, diagnostic procedures, in-hospital and outpatient treatment, and physician visits. RESULTS We found that the median cost of treating a case of anogenital warts was $130. An episode of cervical dysplasia had a median cost of $220, compared to $1300 for an episode of cervical carcinoma in situ. The cost of treating HPV-related invasive cancer varied from $15,000 for cervical cancer to $33,000 for oral cavity cancer. Overall, 80% ($145 million) of the total cost was attributable to HPV infection. Cervical screening and follow-up accounted for $96 million (66%) of all costs and this cost component has declined following the introduction of new screening guidelines. CONCLUSIONS Overall, the average direct medical cost of HPV infection was $720 per newborn. The economic burden of HPV remains significant, although changes in cervical screening guidelines, prompted by the introduction of a public HPV vaccine program, appear to have promoted a promising trend towards lower costs.
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Affiliation(s)
- Christiaan H Righolt
- Department of Community Health Sciences, Vaccine and Drug Evaluation Centre, University of Manitoba, 337-750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Gurpreet Pabla
- Department of Community Health Sciences, Vaccine and Drug Evaluation Centre, University of Manitoba, 337-750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada
| | - Salaheddin M Mahmud
- Department of Community Health Sciences, Vaccine and Drug Evaluation Centre, University of Manitoba, 337-750 McDermot Avenue, Winnipeg, MB, R3E 0T5, Canada.
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Abstract
Treatment of cervical premalignant lesions (cervical intraepithelial neoplasia; CIN) of different grades is very effective, simple, and safe. The entire transformation zone of the cervix needs to be treated either by an ablative technique (cryotherapy or thermal ablation) or an excisional technique (large loop excision of transformation zone or cold knife conization); the choice of treatment depends on the size and location of the lesion and the type of the transformation zone. The cure rate after ablative treatment of high-grade CIN may be little lower than that after excisional treatment. The simplicity of the technique, low complication rate, and lesser cost make ablative technique the treatment of choice in the low resourced settings for the eligible lesions. In situations where organizing colposcopy and histopathology services is challenging, simple algorithms like screening with visual inspection with acetic acid test and immediate ablative treatment of the visual inspection with acetic acid-positive women has been recommended by the World Health Organization. Such a strategy is effective in preventing subsequent development of high-grade CIN and also ensures high compliance of the screen positive women to treatment.
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Affiliation(s)
- Partha Basu
- Screening Group, Early Detection and Prevention Section, International Agency for Research on Cancer, Lyon, France.
| | - Katayoun Taghavi
- Institute of Social and Preventative medicine, University of Bern, Bern, Switzerland
| | - Shang-Ying Hu
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sushma Mogri
- Department of Obstetrics and Gynecology, American International Institute of Medical Sciences, Udaipur, India
| | - Smita Joshi
- Jehangir Clinical Development Centre, Jehangir Hospital Premises and Prayas, Pune, India
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Tainio K, Athanasiou A, Tikkinen KAO, Aaltonen R, Cárdenas J, Hernándes, Glazer-Livson S, Jakobsson M, Joronen K, Kiviharju M, Louvanto K, Oksjoki S, Tähtinen R, Virtanen S, Nieminen P, Kyrgiou M, Kalliala I. Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis. BMJ 2018; 360:k499. [PMID: 29487049 PMCID: PMC5826010 DOI: 10.1136/bmj.k499] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To estimate the regression, persistence, and progression of untreated cervical intraepithelial neoplasia grade 2 (CIN2) lesions managed conservatively as well as compliance with follow-up protocols. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1 January 1973 to 20 August 2016. ELIGIBILITY CRITERIA Studies reporting on outcomes of histologically confirmed CIN2 in non-pregnant women, managed conservatively for three or more months. DATA SYNTHESIS Two reviewers extracted data and assessed risk of bias. Random effects model was used to calculate pooled proportions for each outcome, and heterogeneity was assessed using I2 statistics. MAIN OUTCOME MEASURES Rates of regression, persistence, or progression of CIN2 and default rates at different follow-up time points (3, 6, 12, 24, 36, and 60 months). RESULTS 36 studies that included 3160 women were identified (seven randomised trials, 16 prospective cohorts, and 13 retrospective cohorts; 50% of the studies were at low risk of bias). At 24 months, the pooled rates were 50% (11 studies, 819/1470 women, 95% confidence interval 43% to 57%; I2=77%) for regression, 32% (eight studies, 334/1257 women, 23% to 42%; I2=82%) for persistence, and 18% (nine studies, 282/1445 women, 11% to 27%; I2=90%) for progression. In a subgroup analysis including 1069 women aged less than 30 years, the rates were 60% (four studies, 638/1069 women, 57% to 63%; I2=0%), 23% (two studies, 226/938 women, 20% to 26%; I2=97%), and 11% (three studies, 163/1033 women, 5% to 19%; I2=67%), respectively. The rate of non-compliance (at six to 24 months of follow-up) in prospective studies was around 10%. CONCLUSIONS Most CIN2 lesions, particularly in young women (<30 years), regress spontaneously. Active surveillance, rather than immediate intervention, is therefore justified, especially among young women who are likely to adhere to monitoring. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2014: CRD42014014406.
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Affiliation(s)
- Karoliina Tainio
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antonios Athanasiou
- Department of Obstetrics and Gynaecology, University Hospital of Ioannina, Ioannina, Greece
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka Aaltonen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Hernándes
- National Center for Health Technology Excellence (CENETEC) Direction of Health Technologies assessment, Mexico City, Mexico
| | - Sivan Glazer-Livson
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maija Jakobsson
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Joronen
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Mari Kiviharju
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karolina Louvanto
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Sanna Oksjoki
- Department of Obstetrics and Gynaecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Riikka Tähtinen
- Department of Obstetrics and Gynaecology, Kuopio University Hospital, Kuopio, Finland
| | - Seppo Virtanen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Nieminen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Kyrgiou
- Institute of Reproduction and Developmental Biology, Department of Surgery & Cancer, Imperial College, London W12 0NN, UK
- West London Gynaecological Cancer Center, Queen Charlotte's & Chelsea-Hammersmith Hospital, Imperial Healthcare NHS Trust, London, UK
| | - Ilkka Kalliala
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute of Reproduction and Developmental Biology, Department of Surgery & Cancer, Imperial College, London W12 0NN, UK
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Abstract
High-risk human papillomavirus (HPV) infection is known to be a necessary factor for cervical and anogenital malignancies. Cervical cancers account for over a quarter of a million deaths annually. Despite the availability of prophylactic vaccines, HPV infections remain extremely common worldwide. Furthermore, these vaccines are ineffective at clearing pre-existing infections and associated preinvasive lesions. As cervical dysplasia can regress spontaneously, a therapeutic HPV vaccine that boosts host immunity could have a significant impact on the morbidity and mortality associated with HPV. Therapeutic vaccines differ from prophylactic vaccines in that they are aimed at generating cell-mediated immunity rather than neutralising antibodies. This review will cover various therapeutic vaccine strategies in development for the treatment of HPV-associated lesions and cancers.
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Affiliation(s)
- Gemma Hancock
- Nuffield Department of Medicine, University of Oxford and Oxford NIHR Biomedical Research Centre, NDM Research Building, Old Road Campus, Headington, Oxford, UK.
| | - Karin Hellner
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK.
| | - Lucy Dorrell
- Nuffield Department of Medicine, University of Oxford and Oxford NIHR Biomedical Research Centre, NDM Research Building, Old Road Campus, Headington, Oxford, UK; Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK.
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Hederlingova J, Redman CW, Zahumensky J. Conservative management of biopsy confirmed high-grade squamous intraepithelial lesions. ACTA ACUST UNITED AC 2018; 118:732-735. [PMID: 29322804 DOI: 10.4149/bll_2017_138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Follow-up of women with biopsy-confirmed CIN2+ who were either treated immediately with LLETZ or managed conservatively to determine the rates of patients back on routine screening programme after a median of three years in two groups. METHODS In this retrospective study, 310 patients were involved who had undergone biopsy with result of CIN2+ between January 2011 and December 2014. Depending on the management, i.e. based on whether cytology and colposcopy follow-up or immediate treatment were performed, they were divided in two groups. Then the number of patients back on routine screening up to 15/2/2016 as well as the results of last cytology were compared within both groups. RESULTS A total of 310 women at average age of 30 years met the inclusion criteria. Of them, 230 (74 %) had immediate treatment whereas 80 (26 %) were managed conservatively. There were no statistically significant demographic differences between the two groups. The mean time of follow up was 1.091 days (2.98 years). The patients managed conservatively required more follow-up visits at colposcopy clinic (p<0.001). The last documented cytology in the immediate treatment group was negative in 93 % and low-grade/borderline in 7 % of patients, while in the conservative management group, it was negative in 84 %, low-grade/borderline in 15 % and high-grade in 1 % of patients (p = 0.015). Overall, the proportions of patients who are back on routine screening recall are 96 % and 87.5 % for the immediate treatment and conservatively managed groups, respectively (p=0.022). CONCLUSION The conservative management of high-grade CIN with cytology and colposcopic follow up is an OPTION in selected group of patients, but it cannot be routinely recommended (Tab. 2, Ref. 20).
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Abstract
Human papillomavirus (HPV) is a common infection in kidney transplant recipients. HPV causes cervical, anal, vulvar, vaginal, penile and head and neck cancers. Kidney transplant recipients have a disproportionate burden of disease given prolonged immunosuppression. Given the long pre-invasive state of precancer lesions such as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) most HPV-cancers are preventable with screening and targeted treatment of disease. Pre-transplant vaccination of age-eligible kidney transplant recipients is otherwise ideal.
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Affiliation(s)
- Peter V Chin-Hong
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, CA.
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Possati-Resende JC, Vazquez FDL, Biot ST, Mauad EC, Talarico T, Fregnani JHTG, Longatto-Filho A. Organized Cervical Cancer Screening Program in Barretos, Brazil: Experience in 18 Municipalities of São Paulo State. Acta Cytol 2017; 62:19-27. [PMID: 29069645 DOI: 10.1159/000480446] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/18/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this report is to demonstrate the Barretos Cancer Hospital initiative of organizational, laboratorial, and human resources training in the implementation of an organized cervical screening program in low-resource settings. METHODS We developed a computational program to report all epidemiological, clinical, and laboratorial findings, and to trace all necessary information to recruit women for regular screening or for referral for complementary exams after liquid-based Pap test analyses. RESULTS All Pap tests were collected in liquid medium and in 2014 more than 160,000 tests were analyzed and 2,900 colposcopy examinations were performed. From 2012 to 2015, the percentage of exams collected increased from 54.6% in 2012 to 62.4% in 2013, 68.4% in 2014, and 71% in 2015. Per 1,000 Pap tests, 0.4 cases of invasive cancer were diagnosed; for in situ carcinoma, 1.9 cases were identified. More importantly, between 2011 and 2015, 89.4% of all carcinomas were detected at clinical stage 0 or I (in situ carcinoma), and only 5% at stages III and IV. CONCLUSIONS Since the organized system was implemented, 98% of women have attended their recall for colposcopy. So far, we have not reached the target of 70% of women for this proposal, as recommended by the international standards.
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Wyse A, Seah WA, O'Neill J, Byrne P. The use of cold coagulation for the treatment of cervical intraepithelial neoplasia. Ir Med J 2017; 110:565. [PMID: 28737306] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In 2015, Cold Coagulation was introduced as a treatment for cervical intraepithelial neoplasia (CIN) at our colposcopy clinic. We reviewed the 6-month follow up data of the first 200 women who underwent Cold Coagulation using cytology and HPV status as tests of cure (TOC). A random sample of 200 patients treated by Large Loop Excision of the Transformation Zone (LLETZ) during the same period was used to compare treatment outcome. Six months following treatment,173 (86.5%) of the women treated by CC and 167 (83.5%) treated by LLETZ had negative cytology. (x2= P>0.05). 148 (74%) treated by Cold Coagulation and 166 (83%) treated by LLETZ were HPV negative (x2= P<0.05). One hundred and thirty-nine (70%) women treated by Cold Coagulation and 152 (76%) treated with LLETZ had normal cytology and were HPV negative. This audit of our initial experience supports the observation that Cold Coagulation is as effective as LLETZ in the management of CIN when cervical cytology is used as a test of cure.
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Affiliation(s)
- A Wyse
- Colposcopy Department, Rotunda Hospital, Dublin 1, Ireland
| | - W A Seah
- Colposcopy Department, Rotunda Hospital, Dublin 1, Ireland
| | - J O'Neill
- Colposcopy Department, Rotunda Hospital, Dublin 1, Ireland
| | - P Byrne
- Colposcopy Department, Rotunda Hospital, Dublin 1, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons, 123 St. Stephens Green, Dublin 2, Ireland
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Sparic R, Dotlic J, Kovac J, Babovic I, Buzadzic S, Mirkovic L, Nejkovic L, Stamenkovic J. Management of cervical dysplasia in patient with Müllerian anomaly: diagnostic and therapeutic challenges. EUR J GYNAECOL ONCOL 2017; 38:469-472. [PMID: 29693895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE The study aim was to report diagnostic and therapeutic challenges in treatment of a patient with cervical dysplasia and con- genital uterine anomaly. CASE REPORT A 53-year-old women with Müllerian anomaly - uterus duplex (bicorporal septate uterus) and Y-shaped endocervical canal was referred due to repeated abnormal Pap smears. She underwent endocervical curettage of both canals and the endocervical septum biopsy which revealed presence of cervical intraepithelial neoplasia (CIN) III. Cervical conization was considered technically unfeasible because of abnormal cervical anatomy (lesions deep in the cervical canal on the cervical bifurcation where the cervical wall is the thickest). Classical open abdominal hysterectomy was performed. Patient had two almost equally-sized, symmetrical uterine bodies connected in the isthmico-cervical region, with normal left and obstructed right hemi-vagina. Postoperative histopathological findings confirmed that dysplasia was located in the region where two endocervical canals conjoined. CONCLUSION Diagnostic and therapeutic approach to patients with uterine anomalies has to be individualized, based on anomaly type, patient's age, reproductive history, and patient's preferences.
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Abstract
The high prevalence of abnormal cervical cytology in the context of immunosuppression has been recognized for many years. In response to repeated observations of cervical cancers in HIV-infected women, moderate and severe cervical dysplasia were designated as early symptomatic HIV infection (Category B) by the Centers for Disease Control and Prevention (CDC) in 1993, and invasive cervical cancer as an AIDS-defining condition (Category C). HIV-infected women, therefore, differ from the general population not only with a greater risk for more, but also potentially more severe cervical disease. In the era of highly active antiretroviral therapy, with HIV-infected women living for longer, there is a clear need to address this increased risk with appropriate management guidelines which this review attempts to provide.
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Affiliation(s)
- Dennis Danso
- Harrison Wing, Department of GUM/HIV Medicine, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK.
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Agnello A, Bevilacqua L, Ariviello R, Bandieramonte G, Peroni M, Simoncini E, Verdi P, Zanardi C. Infezioni virali in ginecologia: un problema risolto? Minerva Ginecol 2016; 68:388-391. [PMID: 27206065] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The aim of this observational study was to evaluate the effectiveness of a dietary integrator containing methionine, zinc, Echinacea angustifolia and E. purpurea, probiotics, and antioxidant factors (Immuno Gin) in the treatment of mild cervical dysplasia associated with human papillomavirus (HPV) infection. The study sample was 95 women (age range, 31-55 years) resident in various cities in Italy. Initial Pap test results showed abnormal changes in cervical cells described as atypical squamous cells of undetermined significance (ASC-US) and HPV infection in 23/95 women, 3 of which received the study product. Follow-up repeat Pap testing at 6 months returned normal test results in all 3. In 12 of the 20 women who did not receive treatment with the study product, the repeat Pap test at 6 months showed normal results, whereas persistence of lesions was observed in the other 8 women, with progression to low-grade squamous intraepithelial lesion (LSIL) in one case. Forty-five women presented initially with abnormal changes in cervical cells described as LSIL and HPV infection. Twenty received treatment with the study product; the repeat Pap test at 6 months showed normal results in 15 and no change in lesions in the other 5. Among the 25 women who did not receive treatment with the study product, the repeat Pap test at 6 months showed normal results in 13, whereas persistence of lesions was noted in the other 12, with progression to high-grade squamous intraepithelial lesion - moderate cervical intraepithelial lesion 2 (HSIL - CIN 2) in one case. Twenty-seven women with vulvoperineal condylomatosis received treatment with the study product, as described above, plus biophysical treatment of the lesions. At the 6-month follow-up assessment, no relapse of lesions occurred in 19, whereas relapse was noted in the other 8. Though the study sample is too small to draw statistically significant conclusions, the percentage of cases of lesion regression among the women treated with the study product was slightly higher than in those who did not receive treatment. Use of the study product may provide clinical benefit by stimulating immune defenses against HPV infection.
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Affiliation(s)
- Antonella Agnello
- Liberi professionisti, Associazione Ginecologi Extra-Ospedalieri (A.G.E.O.), Italia -
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Tsikouras P, Zervoudis S, Manav B, Tomara E, Iatrakis G, Romanidis C, Bothou A, Galazios G. Cervical cancer: screening, diagnosis and staging. J BUON 2016; 21:320-325. [PMID: 27273940] [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] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Purpose: Despite the widespread screening programs, cervical cancer remains the third most common cancer in developing countries. Based on the implementation of cervical screening programs with the referred adoption of improved screening methods in cervical cytology with the knowledge of the important role of the human papilloma virus (HPV) it's incidence is decreased in the developed world. Even if cervical HPV infection is incredibly common, cervical cancer is relatively rare. Depending on the rarity of invasive disease and the improvement of detection of pre-cancerous lesions due to the participation in screening programs, the goal of screening is to detect the cervical lesions early in order to be treated before cancer is developed. In populations with many preventive screening programs, a decrease in cervical cancer mortality of 50-75% is mentioned over the past 50 years. The preventive examination of vagina and cervix smear, Pap test, and the HPV DNA test are remarkable diagnostic tools according to the American Cancer Association guidelines, in the investigation of asymptomatic women and in the follow up of women after the treatment of pre-invasive cervical cancer. The treatment of cervical cancer is based on the FIGO 2009 cervical cancer staging.
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Affiliation(s)
- Panagiotis Tsikouras
- University General Hospital and University of Alexandroupolis, Alexandroupolis, Greece
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Kacperczyk J, Bartnik P, Romejko-Wolniewicz E, Jalinik K. Results of Further Diagnostic Procedures Among Patients with Cytological Characteristics of Minor Changes on Pap Smears. Anticancer Res 2016; 36:1023-1026. [PMID: 26976993] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) are the two most common results of positive Pap smears. AIM The aim of this study was to compare the management of patients with ASCUS and LSIL. PATIENTS AND METHODS All procedures were performed between 2003 and 2014 in an outpatient clinic affiliated to a tertiary referral center, and included Pap smears, colposcopy, histology and invasive treatment. RESULTS There were 131 patients in the ASCUS group and 84 in the LSIL group. Further negative cytological results were obtained more frequently among the ASCUS group than the LSIL group [relative risk (RR)=1.18, 95% confidence interval (CI)=1.33-2.40; p<0.001]. Histological results revealed higher occurrence of cervical intraepithelial neoplasia grade III or invasive squamous cancer in the LSIL group than the ASCUS group [RR=6.8 (95% CI=0.95-144.63), p=0.033]. Patients from the LSIL group more frequently required invasive treatment [RR=2.53, 95% CI=1.40-4.67, p=0.001]. CONCLUSION Diagnosis of ASCUS is associated with more frequent cases of total remission in follow-up Pap smears and requires for less-invasive management.
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Affiliation(s)
- Joanna Kacperczyk
- Students' Scientific Group affiliated to the Second Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Bartnik
- Students' Scientific Group affiliated to the Second Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Romejko-Wolniewicz
- Second Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Jalinik
- Second Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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Bakhidze EV, Berlev IV, Arkhangelskaya PA, Malek AV. [Possibilities of estimating the prognosis for development of preinvasive cervical neoplasia by the latest molecular biology methods]. Vopr Onkol 2016; 62:397-400. [PMID: 30462900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Secondary prevention of cervical cancer is the identification and treatment for preinvasive forms of the disease, which include cervical intraepithelial neoplasia (CIN). The traditional method of identification of CIN is cytological however the sensitivity and specificity of this method is limited. The efficacy of a test for human papillomavirus as well as new molecular-biological methods for assessing the prognosis of development of dysplasia and choice of appropriate treatment tactics are still in the process of discussion. The article contains information about different possibilities of using molecular-biological methods for assessing the prognosis of development of CIN and cervical cancer.
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Morris E, Roett MA. Genital Cancers in Women: Cervical Cancer. FP Essent 2015; 438:18-23. [PMID: 26569047] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In 2015 in the United States, it is estimated there will be approximately 12,900 new patients with cervical cancer and 4,100 will die of the disease. If diagnosed at a localized stage, the 5-year survival rate exceeds 90%. Human papillomavirus (HPV) infection is the main risk factor for cervical cancer. Current recommendations for cervical cancer screening include Papanicolaou (Pap) testing every 3 years for women ages 21 to 29 years. For women ages 30 to 65 years, an alternative is screening with Pap and HPV testing every 5 years. If screening results are abnormal, further evaluation can be guided by an algorithm. For a diagnosis of carcinoma in situ or grade 3 cervical intraepithelial neoplasia (CIN), treatment typically involves ablation or excision. Women with CIN 1 or CIN 2 that persists typically are treated with the same methods. For women diagnosed with early-stage invasive cancer, standard treatment is radical hysterectomy. More advanced cancers also are treated with surgery, but chemotherapy and/or radiation also may be used depending on cancer stage. Because most cervical cancer is caused by HPV, it is potentially preventable with HPV vaccination, which is recommended for females and males, ideally beginning at age 11 or 12 years.
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Affiliation(s)
- Elise Morris
- Georgetown University-Providence Hospital Family Medicine Residency, 4000 Reservoir Road NW, Washington, DC 20007
| | - Michelle A Roett
- Fort Lincoln Family Medicine Center, 4151 Bladensburg Road, Colmar Manor, MD 20722
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López-Alegría F, Poblete OQ, De Lorenzi DS, Oyanedel JCS. Clinical management of the first ASCUS report in Chile. Prospective single-cohort study. SAO PAULO MED J 2015; 133:480-7. [PMID: 26465817 PMCID: PMC10496554 DOI: 10.1590/1516-3180.2014.9142511] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 11/09/2014] [Accepted: 11/25/2014] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Worldwide, there is no single strategy for optimal management of patients with ASCUS (atypical squamous cells of undetermined significance) cytology reports. The objective of this study was to determine the kind of clinical management conducted among women with a first ASCUS Pap smear report. DESIGN AND SETTING Prospective single cohort study at a cervical pathology unit in Santiago, Chile. METHODS This was an epidemiological, descriptive, observational and quantitative follow-up study on a cohort of women with ASCUS cytological reports. RESULTS In the screening phase, 92,001 cervical cytological smears were collected in primary healthcare clinics. In the diagnostic phase, all women with a first ASCUS report were selected (n = 446). These women were asked to undergo the Pap test again and it was found that 301 women had normal results, 62 women had abnormal results and 83 did not repeat the test. In the diagnostic confirmation phase, the 62 women with abnormal results underwent colposcopy and, from these results, 58 of them underwent a biopsy. The results from the biopsies showed that 16 women had negative histological reports, 13 had CIN 1 and 29 had CIN 2+. In the treatment phase, the 42 women with lesions underwent a variety of treatments, according to the type of lesion. In the post-treatment phase, cytological and colposcopic monitoring was instituted. CONCLUSION The clinical management consisted of traditional management of screening, diagnosis, diagnostic confirmation, treatment and post-treatment monitoring.
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Affiliation(s)
| | | | - Dino Soares De Lorenzi
- Department of Obstetrics and Gynecology, Universidade de Caxias do Sul, Caxias do Sul, Rio Grande do Sul, Brazil
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Östensson E, Fröberg M, Leval A, Hellström AC, Bäcklund M, Zethraeus N, Andersson S. Cost of Preventing, Managing, and Treating Human Papillomavirus (HPV)-Related Diseases in Sweden before the Introduction of Quadrivalent HPV Vaccination. PLoS One 2015; 10:e0139062. [PMID: 26398189 PMCID: PMC4580320 DOI: 10.1371/journal.pone.0139062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/07/2015] [Indexed: 11/18/2022] Open
Abstract
Objective Costs associated with HPV-related diseases such as cervical dysplasia, cervical cancer, and genital warts have not been evaluated in Sweden. These costs must be estimated in order to determine the potential savings if these diseases were eradicated and to assess the combined cost-effectiveness of HPV vaccination and cervical cancer screening. The present study aimed to estimate prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts from a societal perspective in Sweden in 2009, 1 year before the quadrivalent HPV vaccination program was implemented. Methods and Materials Data from the Swedish cervical cancer screening program was used to calculate the costs associated with prevention (cytological cervical cancer screening), management (colposcopy and biopsy following inadequate/abnormal cytological results), and treatment of CIN. Swedish official statistics were used to estimate treatment costs associated with cervical cancer. Published epidemiological data were used to estimate the number of incident, recurrent, and persistent cases of genital warts; a clinical expert panel assessed management and treatment procedures. Estimated visits, procedures, and use of medications were used to calculate the annual cost associated with genital warts. Results From a societal perspective, total estimated costs associated with cervical cancer and genital warts in 2009 were €106.6 million, of which €81.4 million (76%) were direct medical costs. Costs associated with prevention, management, and treatment of CIN were €74 million; screening and management costs for women with normal and inadequate cytology alone accounted for 76% of this sum. The treatment costs associated with incident and prevalent cervical cancer and palliative care were €23 million. Estimated costs for incident, recurrent and persistent cases of genital warts were €9.8 million. Conclusion Prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts are substantial. Defining these costs is important for future cost-effectiveness analyses of the quadrivalent HPV vaccination program in Sweden.
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Affiliation(s)
- Ellinor Östensson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Maria Fröberg
- Department of Neurobiology, Care Science and Society, Centre for Family Medicine and Community Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Amy Leval
- Department of Medicine, Infectious Disease Unit, Karolinska Institutet, Stockholm, Sweden
- Department of Communicable Disease Control and Prevention for Stockholm County, Stockholm, Sweden
| | - Ann-Cathrin Hellström
- Department of Oncology-Pathology, Karolinska University Hospital-Solna, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Bäcklund
- Department of Medicine, Solna (MedS), K2, Karolinska Institutet, Stockholm, Sweden
| | - Niklas Zethraeus
- Medical Management Centre (MMC), Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Sonia Andersson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Carcopino X, Camus C, Halfon P. [Diagnosis and clinical management of cervical HPV infections]. Presse Med 2015; 44:716-26. [PMID: 26067573 DOI: 10.1016/j.lpm.2015.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 01/30/2015] [Accepted: 02/17/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Xavier Carcopino
- Service de gynécologie-obstétrique du CHU Marseille Nord, 13000 Marseille, France; Université d'Aix-Marseille Université (AMU), faculté de médecine, 13000 Marseille, France.
| | - Claire Camus
- Hôpital Européen, laboratoire Alphabio, service maladies infectieuses, 13000 Marseille, France
| | - Philippe Halfon
- Hôpital Européen, laboratoire Alphabio, service maladies infectieuses, 13000 Marseille, France
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Cendejas BR, Smith-McCune KK, Khan MJ. Does treatment for cervical and vulvar dysplasia impact women's sexual health? Am J Obstet Gynecol 2015; 212:291-7. [PMID: 24881827 DOI: 10.1016/j.ajog.2014.05.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/20/2014] [Accepted: 05/27/2014] [Indexed: 11/17/2022]
Abstract
Human papillomavirus-associated disease represents an immense public health burden worldwide. Persistent human papillomavirus infection can lead to the development of cervical dysplasia and vulvar dysplasia, both of which have been increasing in incidence in women in recent years. Numerous studies have focused on methods for screening and diagnosis of cervical dysplasia, but few have looked at the effects of treatment on women's psychological and sexual health. Even fewer studies have addressed these issues in women with vulvar dysplasia. The aim of this article was to provide a comprehensive review of the existing evidence concerning the impact of therapy for cervical and vulvar precancers on women's sexual function and sexual relationships. We performed a search of the medical literature for the time period up to and including August 2013 on PubMed. The findings from a limited number of studies to date indicate that psychosexual vulnerability increases after diagnosis and treatment of both cervical and vulvar dysplasia. More in-depth research is needed to better understand the effects of different treatment modalities on women's sexual health and relationships during and following treatment.
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Affiliation(s)
- Blanca R Cendejas
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Karen K Smith-McCune
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA
| | - Michelle J Khan
- Division of Women's Reproductive Healthcare, Department of Obstetrics and Gynecology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
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De Vuyst H, Mugo NR, Franceschi S, McKenzie K, Tenet V, Njoroge J, Rana FS, Sakr SR, Snijders PJF, Chung MH. Residual disease and HPV persistence after cryotherapy for cervical intraepithelial neoplasia grade 2/3 in HIV-positive women in Kenya. PLoS One 2014; 9:e111037. [PMID: 25343563 PMCID: PMC4208814 DOI: 10.1371/journal.pone.0111037] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 08/01/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess residual cervical intraepithelial neoplasia (CIN) 2/3 disease and clearance of high-risk (hr) human papillomavirus (HPV) infections at 6 months after cryotherapy among HIV-positive women. DESIGN Follow-up study. METHODS 79 HIV-positive women received cryotherapy for CIN2/3 in Nairobi, Kenya, and underwent conventional cytology 6 months later. Biopsies were performed on high grade cytological lesions and hrHPV was assessed before (cervical cells and biopsy) and after cryotherapy (cells). RESULTS At 6 months after cryotherapy CIN2/3 had been eliminated in 61 women (77.2%; 95% Confidence Interval, (CI): 66.4-85.9). 18 women (22.8%) had residual CIN2/3, and all these women had hrHPV at baseline. CD4 count and duration of combination antiretroviral therapy (cART) were not associated with residual CIN2/3. CIN3 instead of CIN2 was the only significant risk factor for residual disease (odds ratio, OR vs CIN2 = 4.3; 95% CI: 1.2-15.0) among hrHPV-positive women after adjustment for age and HPV16 infection. Persistence of hrHPV types previously detected in biopsies was found in 77.5% of women and was associated with residual CIN2/3 (OR = 8.1, 95% CI: 0.9-70). The sensitivity, specificity, and negative predictive value of hrHPV test in detecting residual CIN2/3 were 0.94, 0.36, and 0.96 respectively. CONCLUSIONS Nearly one quarter of HIV-positive women had residual CIN2/3 disease at 6 months after cryotherapy, and the majority had persistent hrHPV. CD4 count and cART use were not associated with residual disease or hrHPV persistence. The value of hrHPV testing in the detection of residual CIN2/3 was hampered by a low specificity.
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Affiliation(s)
- Hugo De Vuyst
- International Agency for Research on Cancer, Lyon, France
| | - Nelly R. Mugo
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Kevin McKenzie
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Vanessa Tenet
- International Agency for Research on Cancer, Lyon, France
| | - Julia Njoroge
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | | | - Peter J. F. Snijders
- Department of Pathology, Vrije Universiteit Medical Center, Amsterdam, the Netherlands
| | - Michael H. Chung
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
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Mehlhorn G, Hautmann SK, Koch MC, Strehl JD, Hartmann A, Hilfrich R, Beckmann MW, Griesser H. HPV16-L1-specific antibody response is associated with clinical remission of high-risk HPV-positive early dysplastic lesions. Anticancer Res 2014; 34:5127-5132. [PMID: 25202103] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND/AIM The present study was aimed at clarifying if use of a rapid human papillomavirus type 16 L1-specific antibody test could be used to improve clinical management of high-risk HPV-positive low-grade squamous intraepithelial lesion (LSIL)/high-grade squamous intraepithelial lesion (HSIL). PATIENTS AND METHODS The study was nested within a prospective study of 801 patients with early dysplastic high-risk HPV-positive lesions to examine the prognostic significance of HPV-L1 protein detection. Serum samples of 87 patients were tested with a rapid HPV16-L1-specific antibody test. The results were correlated with the clinical outcome during 66 months of follow-up. RESULTS A combined analysis of the 22 antibody-positive women showed that 17 were also L1 protein-positive, and 5 were L1 capsid protein-negative. An HPV-specific immune competence strongly correlates with clinical remission of low-grade squamous intraepithelial lesion (76.6%). For L1 antigen and HPV16-L1 antibody double-positive women, the risk of progression to cervical intraepithelial neoplasia grade 3 was low (5.8%). CONCLUSION The rapid anti-HPV16-L1 test could be a promising tool to improve risk assessment and appropriate clinical management of high-risk HPV-positive early dysplastic lesions.
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Affiliation(s)
- Grit Mehlhorn
- Department of Gynecology, Erlangen University Hospital, Erlangen, Germany
| | - Simone K Hautmann
- Department of Gynecology, Erlangen University Hospital, Erlangen, Germany
| | - Martin C Koch
- Department of Gynecology, Erlangen University Hospital, Erlangen, Germany
| | - Johanna D Strehl
- Institute of Pathology, Erlangen University Hospital, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Erlangen University Hospital, Erlangen, Germany
| | | | | | - Henrik Griesser
- Department of Pathology and Cytodiagnostics, Laboratory Medicine, Cologne, Germany
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Paul P, Winkler JL, Bartolini RM, Penny ME, Huong TT, Nga LT, Kumakech E, Mugisha E, Jeronimo J. Screen-and-treat approach to cervical cancer prevention using visual inspection with acetic acid and cryotherapy: experiences, perceptions, and beliefs from demonstration projects in Peru, Uganda, and Vietnam. Oncologist 2014; 18 Suppl:6-12. [PMID: 24334477 DOI: 10.1634/theoncologist.18-s2-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 11/17/2022] Open
Abstract
Cervical cancer is preventable but continues to cause the deaths of more than 270,000 women worldwide each year, most of them in developing countries where programs to detect and treat precancerous lesions are not affordable or available. Studies have demonstrated that screening by visual inspection of the cervix using acetic acid (VIA) is a simple, affordable, and sensitive test that can identify precancerous changes of the cervix so that treatment such as cryotherapy can be provided. Government partners implemented screening and treatment using VIA and cryotherapy at demonstration sites in Peru, Uganda, and Vietnam. Evaluations were conducted in the three countries to explore the barriers and facilitating factors for the use of services and for incorporation of screen-and-treat programs using VIA and cryotherapy into routine services. Results showed that use of VIA and cryotherapy in these settings is a feasible approach to providing cervical cancer prevention services. Activities that can help ensure successful programs include mobilizing and educating communities, organizing services to meet women's schedules and needs, and strengthening systems to track clients for follow-up. Sustainability also depends on having an adequate number of trained providers and reducing staff turnover. Although some challenges were found across all sites, others varied from country to country, suggesting that careful assessments before beginning new secondary prevention programs will optimize the probability of success.
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