Towards the global elimination of cervical cancer

Two very effective prevention strategies for cervical cancer exist - vaccination against the human papillomavirus (HPV) and cervical screening with primary HPV testing followed by treatment of precancerous lesions. In 2018, the World Health Organisation called for action towards achieving the global elimination of cervical cancer, and a strategic plan encompassing elimination goals and targets for the scale-up of HPV vaccination, cervical screening and precancer and cancer treatment, particularly in low and middle income countries, will be presented to the 2020 World Health Assembly. The first published estimates suggest that achieving rapid scale-up of both vaccination and twice lifetime cervical screening in all countries would avert up to 13.4 million cervical cancer cases over the next half century, with the majority (but not all) countries achieving incidence of <4 per 100,000 women by 2100. However, there are significant challenges - (i) including vaccine manufacturing pipeline, supply, delivery and hesitancy, (ii) cervical screening HPV self-collection and point-of-care evaluation, acceptability, and scaling up effective precancer treatment processes, (iii) configuration of appropriate referral pathways, cancer treatment services and palliative care for those women who do develop cervical cancer, as well as (iv) the effective financing of both HPV vaccination and cervical screening on a large scale. It is hoped and anticipated that the WHO elimination initiative will galvanise concerted action to address these issues.

Cost-effectiveness of human papillomavirus vaccination in low and middle income countries: a systematic review

The World Health Organization recommends establishing that human papillomavirus vaccination is cost-effective before vaccine introduction. We searched Pubmed, Embase and the Cochrane Library to 1 April 2012 for economic evaluations of human papillomavirus vaccination in low and middle income countries. We found 25 articles, but almost all low income countries and many middle income countries lacked country-specific studies. Methods, assumptions and consequently results varied widely, even for studies conducted for the same country. Despite the heterogeneity, most studies conclude that vaccination is likely to be cost-effective and possibly even cost saving, particularly in settings without organized cervical screening programmes. However, study uncertainty could be reduced by clarity about vaccine prices and vaccine delivery costs. The review supports extending vaccination to low income settings where vaccine prices are competitive, donor funding is available, cervical cancer burden is high and screening options are limited.

Experience with HPV self-sampling and clinician-based sampling in women attending routine cervical screening in the Netherlands

Several countries offer HPV self-sampling for screening non-attendees. It is assumed that screening attendees also prefer self-sampling to clinician-based sampling, however, little research has been conducted with respect to this. Women participating in the IMPROVE-study were randomised (1:1) to self- or clinician-collected HPV testing, and HPV-positive women were retested using the other collection method. Three different questionnaires were sent out among a subset of participating women: Q1) HPV-positive women from both study groups were asked about their experiences with self-sampling and clinician-based sampling (n = 497); Q2) HPV-negative women from the self-sampling group were asked about their experiences with self-sampling (n = 2366); and Q3) HPV-negative women in the clinician-collection group were asked about their experiences with clinician-based sampling (n = 2092). Response rates ranged from 71.6 to 79.4%. Women reported significantly lower levels of shame, nervousness, discomfort and pain during self-sampling compared to clinician-based sampling. However, trust in correct sampling was significantly higher during clinician-based sampling. The majority of women in group Q1 preferred self-sampling (76.5%) to clinician-based sampling (11.9%) in future screening, while 11.6% of women reported to have no preference for either method. To conclude, women from a regular screening population have a positive attitude towards self-sampling but express some concerns with respect to accuracy. The majority prefers self-sampling to clinician-based sampling in future screening. Based on these results, a screening approach where women can choose for either self-sampling or clinician-based sampling seems highly justifiable.

HPV-FRAME: A consensus statement and quality framework for modelled evaluations of HPV-related cancer control

Intense research activity in HPV modelling over this decade has prompted the development of additional guidelines to those for general modelling. A specific framework is required to address different policy questions and unique complexities of HPV modelling. HPV-FRAME is an initiative to develop a consensus statement and quality-based framework for epidemiologic and economic HPV models. Its development involved an established process. Reporting standards have been structured according to seven domains reflecting distinct policy questions in HPV and cancer prevention and categorised by relevance to a population or evaluation. Population-relevant domains are: 1) HPV vaccination in pre-adolescent and young adolescent individuals; 2) HPV vaccination in older individuals; 3) targeted vaccination in men who have sex with men; 4) considerations for individuals living with HIV and 5) considerations for low- and middle-income countries. Additional considerations applicable to specific evaluations are: 6) cervical screening or integrated cervical screening and HPV vaccination approaches and 7) alternative vaccine types and alternative dosing schedules. HPV-FRAME aims to promote the development of models in accordance with an explicit framework, to better enable target audiences to understand a model's strength and weaknesses in relation to a specific policy question and ultimately improve the model's contribution to informed decision-making.

Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: A systematic narrative review

Cervical cancer mortality in the United Kingdom (UK) has decreased over the last decade, largely due to uptake of cervical cancer screening. However, only those with a female gender marker on their health records are invited, creating a significant barrier to gender minorities accessing screening. We undertook a systematic review to synthesise published literature on cervical cancer screening among eligible gender minorities, aiming to identify barriers and facilitators that might inform changes in UK policy and clinical practice. We conducted a broad search across Medline, Embase, PsycInfo and Global Health databases to 3rd January 2020 and included any original, peer-reviewed research, published in the English language that reported on cervical cancer screening among gender minorities assigned female at birth (AFAB). Twenty-seven studies were critically appraised and included in the final synthesis, which identified significant disparities in cervical cancer screening uptake between gender minorities AFAB and cis women. It revealed a lack of knowledge surrounding the relationship between gender minority status and cervical cancer risk among both service users and providers and highlighted significant barriers to access for gender minorities AFAB. Cervical cancer screening was not universally associated with dysphoria among gender minorities AFAB and we recommend that providers explore patients' preferences around screening, while avoiding assumptions. Providers should be proficient in examination techniques that maximise patient autonomy and minimise gender dysphoria or pain. Self-swabs for high-risk HPV may provide a more acceptable, evidence-based, alternative to Pap smears but there remains a need for further UK-specific research, to inform changes in policy.

Clinical performance of high-risk HPV testing on self-samples versus clinician samples in routine primary HPV screening in the Netherlands: An observational study

Background

High-risk human papillomavirus (hrHPV) testing on self-collected samples has potential as a primary screening tool in cervical screening, but real-world evidence on its accuracy in hrHPV-based screening programmes is lacking.

Methods

In the Netherlands, women aged 30–60 years invited for cervical screening can choose between sampling at the clinician's office (Cervex Brush) or self-sampling at home (Evalyn Brush). HrHPV testing is performed using Roche Cobas 4800. We collected screening test results between January 2017 and March 2018 and histological follow-up until August 2019. The main outcome measures were mean cycle threshold (Ct) value, cervical intraepithelial neoplasia (CIN) grade 3 or cancer (CIN3+) and CIN grade 2 or worse (CIN2+).

Findings

30,808 women had a self-collected and 456,207 had a clinician-collected sample. In hrHPV-positive women with adequate cytology, Ct values were higher for self-collection than clinician-collection with a mean Ct difference of 1·25 (95% CI 0·98–1·52) in women without CIN2+, 2·73 (1·75–3·72) in CIN2 and 3·59 (3·03–4·15) in CIN3+. The relative sensitivity for detecting CIN3+ was 0·94 (0·90–0·97) for self-collection versus clinician-collection and the relative specificity was 1·02 (1·02–1·02).

Interpretation

The clinical accuracy of hrHPV testing on a self-collected sample for detection of CIN3+ is high and supports its use as a primary screening test for all invited women. Because of the slightly lower sensitivity of hrHPV testing on a self-collected compared to a clinician-collected sample, an evaluation of the workflow procedure to optimise clinical performance seems warranted.

Funding

National Institute for Public Health and the Environment (the Netherlands) and the European Commission.

A study of HPV typing for the management of HPV-positive ASC-US cervical cytologic results

BACKGROUND

In US cervical screening, immediate colposcopy is recommended for women with HPV-positive ASC-US (equivocal) cytology. We evaluated whether partial typing by Onclarity™ (BD) might identify HPV-positive women with low enough CIN3+ risk to permit 1-year follow-up instead.

METHODS

The NCI-Kaiser Permanente Northern California Persistence and Progression cohort includes a subset of 13,890 women aged 21+ with HC2 (Qiagen)-positive ASC-US at enrollment; current median follow-up is 3.0years. Using stratified random sampling, we typed 2079 archived enrollment specimens including 329 women subsequently diagnosed with CIN3+, 563 with CIN2, and 1187 with

RESULTS

The 3-year CIN3+ risk for all HC2-positive women with ASC-US was 5.2%; this establishes the "benchmark" risk for colposcopic referral. Hierarchically, 3-year cumulative risks for each typing channel were 16.0% for HPV16, 7.4% for HPV18, 7.0% for HPV31, 7.1% for grouped HPV33/58, 4.3% for HPV52, 3.9% for HPV45, 2.7% for HPV51, 1.6% for HPV39/68/35, and 1.3% for HPV59/56/66.

DISCUSSION

ASC-US linked to HPV16, HPV18, HPV31, or HPV33/58 warrants immediate colposcopy. Optimal management of women with HPV52 or HPV45 is uncertain. Risk of women with only HPV51, HPV39/68/35, or HPV59/56/66 might be low enough to recommend 1-year retesting permitting viral clearance. This strategy would defer colposcopy for 40% of women with HPV-positive ASC-US, half of whom would be cotest-negative at 1-year return. Approximately 10% of those with CIN3 diagnosable at enrollment would be delayed 1year instead. Cost-effectiveness analyses are needed.

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Key Words

• ASC-US
• Cervical screening
• HPV testing
• Triage

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MESH Headings

• Adult
• Atypical Squamous Cells of the Cervix/pathology
• Atypical Squamous Cells of the Cervix/virology
• Female
• Genotype
• Humans
• Papillomaviridae/genetics
• Papillomavirus Infections/virology
• Squamous Intraepithelial Lesions of the Cervix/pathology
• Squamous Intraepithelial Lesions of the Cervix/virology
• Uterine Cervical Neoplasms/pathology
• Uterine Cervical Neoplasms/virology
• Vaginal Smears/methods
• Young Adult
• Uterine Cervical Dysplasia/virology

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Grants

• Z01 CP010124-12 Intramural NIH HHS

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Barriers to cervical screening and interest in self-sampling among women who actively decline screening

OBJECTIVES

Understanding why some women actively decline cervical screening could contribute to tailored intervention development. We explored reasons for non-participation in cervical screening among women who had made an active decision not to attend in the future. We also explored interest in human papillomavirus self-sampling.

METHODS

In a population-based survey of women in Great Britain, home-based computer-assisted interviews were carried out with screening eligible women. Women reported their intention to attend for screening when next invited. They endorsed predefined barriers to screening and indicated their interest in human papillomavirus self-sampling.

RESULTS

Women who had actively declined screening and those who intended to go but were currently overdue (n=543) were included in this analysis. Women who had made an active decision not to be screened in the future were more likely to endorse the barriers 'I have other more important things to worry about' and to perceive screening to be of low relevance based on their sexual behaviour. Most participants (70%) indicated that they would be interested in human papillomavirus self-sampling. Interest in self-sampling was greater among those who reported having had a bad experience of screening in the past, were too busy or embarrassed to attend, or would not want a man to carry out the test.

CONCLUSIONS

Women who had made an active decision not to attend screening felt it was of low relevance to them and that they had more important things to worry about. Shifting the perceived cost-benefit ratio for these women by offering human papillomavirus self-sampling might increase screening participation in this group.

Methylation marker analysis and HPV16/18 genotyping in high-risk HPV positive self-sampled specimens to identify women with high grade CIN or cervical cancer

OBJECTIVES

Methylation marker analysis using bi-marker panel MAL/miR-124-2 is a promising triage test for identifying cervical (pre)cancer in high-risk human papillomavirus (hrHPV) positive women. Bi-marker panel MAL/miR-124-2 can be applied directly on self-sampled cervico-vaginal material and its sensitivity is non-inferior to that of cytology, yet at the cost of more colposcopy referrals. Our objective was to increase specificity of MAL/miR-124-2 methylation analysis by varying the assay thresholds and adding HPV16/18 genotyping.

METHODS

1019 hrHPV-positive women were selected from a randomized controlled self-sampling trial (PROHTECT-3; 33-63 years, n=46,001) and nine triage strategies with methylation testing of MAL/miR-124-2 and HPV16/18 genotyping were evaluated. The methylation assay threshold was set at four different predefined levels which correspond with clinical specificities for end-point cervical intra-epithelial grade 3 or worse (CIN3+) of 50%, 60%, 70%, and 80%.

RESULTS

The CIN3+ sensitivity of methylation analysis decreased (73.5 to 44.9%) while specificity increased (47.2 to 83.4%) when increasing the assay threshold. CIN3+ sensitivity and specificity of HPV16/18 genotyping were 68.0% and 65.6%, respectively. Combined methylation analysis at threshold-80 and HPV16/18 genotyping yielded similar CIN3+ sensitivity as that of methylation only at threshold-50 (77.6%) with an increased specificity (54.8%).

CONCLUSIONS

Combined triage by MAL/miR-124-2 methylation analysis with threshold-80 and HPV16/18 genotyping reaches high CIN3+ sensitivity with increased specificity to identify women with cervical (pre)cancer among HPV self-sample positive women. The combined strategy is attractive as it is fully molecular and identifies women at the highest risk of cervical (pre)cancer because of strongly elevated methylation levels and/or HPV16/18 positivity.

Bethesda Interobserver Reproducibility Study-2 (BIRST-2): Bethesda System 2014

INTRODUCTION

In concert with the 2014 update to the Bethesda System for Reporting Cervical Cytology, a Web-based image interobserver study was performed to evaluate concordance with the "expert panel" interpretation, as was done during the Bethesda 2001 update. The aim was to identify cytomorphologic features and Bethesda reporting categories that represent sources of poor interobserver agreement and see how the trends compared to the first Bethesda Interobserver Reproducibility Study (BIRST).

MATERIALS AND METHODS

Participants were recruited online through national and international cytopathology professional societies. Study participants evaluated 84 previously unpublished web images chosen from the third Bethesda Atlas image set, prior to the release of the atlas. These images spanned all reporting categories and included typical and borderline cytomorphology. Demographic information was collected on level of training, practice patterns, and experience of the participants. Participation was restricted to those correctly answering 2 basic cytopathology questions, ensuring minimal knowledge of gynecologic cytopathology.

RESULTS

A total of 1290 unique individuals attempted access to this Web-based study and 833 correctly answered the two qualifying questions. Of these, 518 respondents completed the survey. Participant origin included: 59% United States, 41% international; 48% cytotechnologists, 41% pathologists, 5% fellows, and 6% other. Practice types were: 39% academic institutions, 29% private hospitals, and 16% commercial laboratories. Overall, the mean participant agreement with the exact Bethesda panel interpretation was 62.8%. The best agreement was found for negative for intraepithelial lesion or malignancy (NILM; 74%) and low-grade squamous intraepithelial lesion (LSIL; 86%) categories. Squamous cell carcinoma (SCC) (63%), high-grade squamous intraepithelial lesion (HSIL; 60%), atypical squamous cells of undetermined significance (ASC-US; 62%) and atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H; 60%) showed slightly lower concordance with the panel interpretations. Cervical glandular lesions were more problematic (33%). Anal samples performed similarly to their gynecologic counterparts. There was similar diagnostic agreement across participant certifications and practice type (academic versus non-academic). Performance was higher for United States and other North America-based participants (P = 0.0104). This significance may be attributed to a language bias, as the survey was only offered in English.

CONCLUSIONS

Similar to the BIRST-1 study conducted in 2001, the most important factor for diagnostic agreement by cytotechnologists, pathologists, and trainees was the a priori difficulty of an image rather than participant training, certification, or experience. Participants showed better general diagnostic agreement with the expert panel interpretations of the material in BIRST-2 than in BIRST-1. Agreement was highest for Bethesda categories of NILM, LSIL, HSIL, and SCC. Concordance for even the borderline ASC-US and ASC-H categories exhibited remarkable improvement in the BIRST-2.

Transitioning from cytology-based screening to HPV-based screening at longer intervals: implications for resource use

Background

Following a recent major review of cervical screening, from 2017 Australia will transition from two-yearly cytology-based screening to five-yearly primary HPV screening, with partial genotyping and direct referral for HPV 16/18 and LBC triage for other oncogenic types. Switching to a longer screening interval will result in transitional fluctuations for volumes of tests before a 'steady state' is reached for the new test volumes. This study aimed to quantify the impact of this transition on year-to-year volumes of screening and follow-up tests and procedures.

Methods

Number of women screened and test volumes from 2015 to 2032 were estimated via a detailed simulation model which explicitly modelled varying screening and HPV vaccination exposure in individual birth cohorts, and fully incorporated how a relatively rapid screening program switch in 2017 would affect both women attending for routine screening and those in surveillance following an abnormality.

Results

Numbers of women screened and HPV tests are predicted to fluctuate in the first screening rounds as a result of the transition to a longer screening interval (mean women screened and HPV tests 1.4 million in the first 5-year period, year-to-year fluctuation > +/−50 %; mean 1.5 million women/HPV tests in third 5-year period, fluctuation approximately +/−25 %). The extent to which this fluctuation was predicted to carry through to secondary tests/procedures was less (fluctuations of +25 %/-31 % in first 5-year period; decreasing to +8 %/-10 % by third round). HPV vaccination is predicted to counteract increases in high grade cytology results, colposcopies and precancer treatments which would otherwise occur due to population increases. Precancer treatments are predicted to drop below 2015 levels within the first few years of program switchover. Mean colposcopy volumes are predicted to be similar to 2015 levels by the third round of HPV-based screening, and also be 25–40 % lower than would have occurred in the absence of HPV vaccination.

Conclusions

While numbers of women attending for screening and HPV tests are anticipated to initially fluctuate as a result of the transition to a longer recommended interval, there is expected to be less fluctuation in follow-up tests and procedures; however these will still have a significant impact on operational aspects of the screening program. Detailed modelling of the switchover process gave important insights into how volumes would be affected.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1375-9) contains supplementary material, which is available to authorized users.

Psycho-social influences upon older women's decision to attend cervical screening: A review of current evidence

Cervical cancer is the fourth most common cancer in women worldwide (WHO, 2016). In many developed countries the incidence of cervical cancer has been significantly reduced by the introduction of organised screening programmes however, in the UK, a fall in screening coverage is becoming a cause for concern. Much research attention has been afforded to younger women but age stratified mortality and incidence data suggest that older women's screening attendance is also worthy of study. This paper provides a review of current evidence concerning the psycho-social influences that older women experience when deciding whether to attend cervical screening. Few studies have focussed on older women and there are significant methodological issues with those that have included them in their samples. Findings from these studies indicate several barriers which may deter older women from screening, such as embarrassment and logistical issues. Drivers to screening include reassurance and a sense of obligation. Physical, social and emotional changes that occur as women age may also have an impact on attendance. This review concludes that there is a clear need for better understanding of the perceptions of older women specifically with regard to cervical cancer and screening. Future research should inform the design of targeted interventions and provision of information to enable informed decision-making regarding cervical screening among older women.

Age-specific HPV prevalence among 116,052 women in Australia's renewed cervical screening program: A new tool for monitoring vaccine impact

Australia's transition to primary human papillomavirus (HPV) based cervical screening, has for the first time, provided a passive mechanism for monitoring the impact of vaccination on infection prevalence among women attending screening. We assessed oncogenic HPV prevalence by single year of age in the first 7  months of the program, using data collected from a large screening laboratory in Victoria, Australia, which is routinely screening using cobas 4800, cobas 6800 and Seegene assays. Among 116,052 primary screening samples from women aged 25-74, 9.25% (95%CI: 9.09-9.42%) had oncogenic HPV detected: 2.14% (95%CI: 2.05-2.22%) were 16/18 positive and 7.12% (95%CI: 6.97-7.27%) were positive for only non-16/18 HPV. Prevalence peaked at age 25-29 then decreased with age, but this was driven by non-16/18 types. HPV16/18 prevalence remained low and flat across ages, contrasting with pre-vaccination epidemiology when HPV16/18 peaked in young women. HPV-based screening can precisely monitor HPV prevalence.

The use of human papillomavirus DNA methylation in cervical intraepithelial neoplasia: A systematic review and meta-analysis

BACKGROUND

Methylation of viral DNA has been proposed as a novel biomarker for triage of human papillomavirus (HPV) positive women at screening. This systematic review and meta-analysis aims to assess how methylation levels change with disease severity and to determine diagnostic test accuracy (DTA) in detecting high-grade cervical intra-epithelial neoplasia (CIN).

METHODS

We performed searches in MEDLINE, EMBASE and CENTRAL from inception to October 2019. Studies were eligible if they explored HPV methylation levels in HPV positive women. Data were extracted in duplicate and requested from authors where necessary. Random-effects models and a bivariate mixed-effects binary regression model were applied to determine pooled effect estimates.

FINDINGS

44 studies with 8819 high-risk HPV positive women were eligible. The pooled estimates for positive methylation rate in HPV16 L1 gene were higher for high-grade CIN (≥CIN2/high-grade squamous intra-epithelial lesion (HSIL) (95% confidence interval (95%CI:72·7% (47·8-92·2))) vs. low-grade CIN (≤CIN1/low-grade squamous intra-epithelial lesion (LSIL) (44·4% (95%CI:16·0-74·1))). Pooled difference in mean methylation level was significantly higher in ≥CIN2/HSIL vs. ≤CIN1/LSIL for HPV16 L1 (11·3% (95%CI:6·5-16·1)). Pooled odds ratio of HPV16 L1 methylation was 5·5 (95%CI:3·5-8·5) for ≥CIN2/HSIL vs. ≤CIN1/LSIL (p < 0·0001). HPV16 L1/L2 genes performed best in predicting CIN2 or worse (pooled sensitivity 77% (95%CI:63-87), specificity 64% (95%CI:55-71), area under the curve (0·73 (95%CI:0·69-0·77)).

INTERPRETATION

Higher HPV methylation is associated with increased disease severity, whilst HPV16 L1/L2 genes demonstrated high diagnostic accuracy to detect high-grade CIN in HPV16 positive women. Direct clinical use is limited by the need for a multi-genotype and standardised assays. Next-generation multiplex HPV sequencing assays are under development and allow potential for rapid, automated and low-cost methylation testing.

FUNDING

NIHR, Genesis Research Trust, Imperial Healthcare Charity, Wellcome Trust NIHR Imperial BRC, European Union's Horizon 2020.

The impact of the COVID-19 pandemic on the Ontario Cervical Screening Program, colposcopy and treatment services in Ontario, Canada: a population-based study

Objective

To describe the immediate impact of the COVID‐19 pandemic on cervical screening, colposcopy and treatment volumes in Ontario, Canada.

Design

Population‐based retrospective observational study.

Setting

Ontario, Canada.

Population

People with a cervix age of 21–69 years who completed at least one cervical screening cytology test, colposcopy or treatment procedure for cervical dysplasia between January 2019 and August 2020.

Methods

Administrative databases were used to compare cervical screening cytology, colposcopy and treatment procedure volumes before (historical comparator) and during the first 6 months of the COVID‐19 pandemic (March–August 2020).

Main outcome measures

Changes in cervical screening cytology, colposcopy and treatment volumes; individuals with high‐grade cytology awaiting colposcopy.

Results

During the first 6 months of the COVID‐19 pandemic, the monthly average number of cervical screening cytology tests, colposcopies and treatments decreased by 63.8% (range: −92.3 to −41.0%), 39.7% (range: −75.1 to −14.3%) and 31.1% (range: −43.5 to −23.6%), respectively, when compared with the corresponding months in 2019. Between March and August 2020, on average 292 (−51.0%) fewer high‐grade cytological abnormalities were detected through screening each month. As of August 2020, 1159 (29.2%) individuals with high‐grade screening cytology were awaiting follow‐up colposcopy.

Conclusions

The COVID‐19 pandemic has had a substantial impact on key cervical screening and follow‐up services in Ontario. As the pandemic continues, ongoing monitoring of service utilisation to inform system response and recovery is required. Future efforts to understand the impact of COVID‐19‐related disruptions on cervical cancer outcomes will be needed.

Tweetable abstract

COVID‐19 has had a substantial impact on cervical screening and follow‐up services in Ontario, Canada.

COVID‐19 has had a substantial impact on cervical screening and follow‐up services in Ontario, Canada.

Impact of disruptions and recovery for established cervical screening programs across a range of high-income country program designs, using COVID-19 as an example: A modelled analysis

COVID-19 has disrupted cervical screening in several countries, due to a range of policy-, health-service and participant-related factors. Using three well-established models of cervical cancer natural history adapted to simulate screening across four countries, we compared the impact of a range of standardised screening disruption scenarios in four countries that vary in their cervical cancer prevention programs. All scenarios assumed a 6- or 12-month disruption followed by a rapid catch-up of missed screens. Cervical screening disruptions could increase cervical cancer cases by up to 5-6%. In all settings, more than 60% of the excess cancer burden due to disruptions are likely to have occurred in women aged less than 50 years in 2020, including settings where women in their 30s have previously been offered HPV vaccination. Approximately 15-30% of cancers predicted to result from disruptions could be prevented by maintaining colposcopy and precancer treatment services during any disruption period. Disruptions to primary screening had greater adverse effects in situations where women due to attend for screening in 2020 had cytology (vs. HPV) as their previous primary test. Rapid catch-up would dramatically increase demand for HPV tests in 2021, which it may not be feasible to meet because of competing demands on the testing machines and reagents due to COVID tests. These findings can inform future prioritisation strategies for catch-up that balance potential constraints on resourcing with clinical need.

Is the recent increase in cervical cancer in women aged 20-24years in England a cause for concern?

The rates of cervical cancer (CxCa) in England among women aged 20-24yrs increased from 2.7 in 2012 to 4.6 per 100,000 in 2014 (p=0.0006). There was concern that the sudden increase was linked to the withdrawal of cervical screening in women aged 20-24 (a policy that affected women born since 1984). We analyse granular data on age and FIGO stage at diagnosis using a generalised linear model to see whether the unprecedented increase in CxCa in young women in 2014 was linked to the change in 2012 to the age at which the first invitation to screening was sent (from 25.0 to 24.5). Annual rates of CxCa per 100,000 women aged 20.0-24.5yrs decreased gradually over time, whereas at age 24.5-25.0yrs they increased from an average of 16 pre-2013 to 49 in 2015. An increase of 20.3 per 100,000 women aged 24.5-25.0yrs (95% CI: 15.2-25.4) was associated with inviting women for screening at age 24.5yrs instead of at age 25.0. At age 25.0-25.5yrs, rates decreased by 23.7 per 100,000 after women were invited at age 24.5yrs (p<0.001). All these changes were limited to stage I CxCa. There was a dramatic increase in diagnoses at age 25yrs in 2009-2011 associated with changing the age at first invitation from 20yrs to 25yrs. No changes were observed at age 26.0-27.0yrs. The increase in CxCa aged 20-24 is attributable to an increase in the proportion of women first screened aged 24.5yrs. The increase was limited to stage I CxCa. There is no evidence of a lack of screening leading to increasing rates.

A cluster randomized trial of strategies to increase uptake amongst young women invited for their first cervical screen: The STRATEGIC trial

Objectives

To measure the feasibility and effectiveness of interventions to increase cervical screening uptake amongst young women.

Methods

A two-phase cluster randomized trial conducted in general practices in the NHS Cervical Screening Programme. In Phase 1, women in practices randomized to intervention due for their first invitation to cervical screening received a pre-invitation leaflet and, separately, access to online booking. In Phase 2, non-attenders at six months were randomized to one of: vaginal self-sample kits sent unrequested or offered; timed appointments; nurse navigator; or the choice between nurse navigator or self-sample kits. Primary outcome was uplift in intervention vs. control practices, at 3 and 12 months post invitation.

Results

Phase 1 randomized 20,879 women. Neither pre-invitation leaflet nor online booking increased screening uptake by three months (18.8% pre-invitation leaflet vs. 19.2% control and 17.8% online booking vs. 17.2% control). Uptake was higher amongst human papillomavirus vaccinees at three months (OR 2.07, 95% CI 1.69–2.53, p < 0.001). Phase 2 randomized 10,126 non-attenders, with 32–34 clusters for each intervention and 100 clusters as controls. Sending self-sample kits increased uptake at 12 months (OR 1.51, 95% CI 1.20–1.91, p = 0.001), as did timed appointments (OR 1.41, 95% CI 1.14–1.74, p = 0.001). The offer of a nurse navigator, a self-sample kits on request, and choice between timed appointments and nurse navigator were ineffective.

Conclusions

Amongst non-attenders, self-sample kits sent and timed appointments achieved an uplift in screening over the short term; longer term impact is less certain. Prior human papillomavirus vaccination was associated with increased screening uptake.

An epidemiological study of cervical and breast screening in India: district-level analysis

Background

Breast cancer and cervical cancer, the most common forms of cancer in women worldwide, are on a fast and steady rise, accounting for more deaths in women than any other cancer in the developing world. Cancer screening tests are an important tool to combat cancer-related morbidity and mortality. World Health Organization aims to accelerate action to achieve Goal 3.4 of the Sustainable Development Goals (SDG 3.4) in order to reduce premature mortality from non-communicable disease, including cancer by one-third by 2030. This study aims to examine the geospatial variation of cervical and breast screening across districts and to identify factors that contribute to the utilization of screening among women in India.

Methods

Until recently, there was no evidence pertaining to screening for cervical and breast cancers at the national level. Information on examination of the breast and cervix from over 699,000 women aged 15–49 years was collected for the first time in the fourth round of National Family Health Survey, 2015–16 (NFHS-4). For the present study, the data were aggregated for all 640 districts in India. Moran’s Index was calculated to check for spatial autocorrelation. Univariate Local Indicators of Spatial Association (LISA) maps were plotted to look for spatial dependence associated with the uptake of screening practices. The spatial error model was employed to check for spatial magnitude and direction.

Results

The common factors associated with uptake of both cervical and breast screening at the district level were; women belonging to a general caste, residing in rural areas, being currently married, and being well-off economically. Being insured was positively associated with the uptake of cervical screening only. This study provides spatial inference by showing geographical variations in screening of cervix and breast across districts of India.

Conclusions

By showing geographical disparities in screening practices across districts of India, this study highlights the importance of ensuring a region-specific and organ-specific approach towards control and prevention of cancer. The identified factors responsible for the uptake of screening could be a guiding force to decide how and where tailored interventions may be best targeted.

Eliminating Cervical Cancer: Progress and Challenges for High-income Countries

In 2020, the World Health Organization launched a major initiative to eliminate cervical cancer globally. The initiative is built around the three key pillars of human papillomavirus (HPV) vaccination, cervical screening and treatment, with associated intervention targets for the year 2030. The '90-70-90' targets specify that 90% of adolescent girls receive prophylactic HPV vaccination, 70% of adult women receive a minimum twice-in-a-lifetime cervical HPV test and 90% receive appropriate treatment for preinvasive or invasive disease. Modelling has shown that if these targets are met, the elimination of cervical cancer, defined as fewer than four cases per 100 000 women per annum, will be achieved within a century. Many high-income countries are well positioned to eliminate cervical cancer within the coming decades, but few have achieved '90-70-90' and many challenges must still be addressed to deliver these critical interventions effectively. This review considers the current status of cervical cancer control in relation to each of the three elimination pillars in high-income countries and discusses some of the developments that will assist countries in reaching these ambitious targets by 2030.

Uptake and acceptability of human papillomavirus self-sampling in rural and remote aboriginal communities: evaluation of a nurse-led community engagement model

BACKGROUND

Aboriginal women experience disproportionately higher rates of cervical cancer mortality yet are less likely to participate in screening for early detection. This study sought to determine whether a community-based HPV self-sampling service model can effectively recruit never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes; and explore the acceptability of the model from the perspective of the participants.

METHODS

Aboriginal women aged 25-69 years of age were recruited from eight rural and remote communities in New South Wales, Australia to participate in HPV self-sampling via a community-based service model. Outcome measures were: number of women screened by HPV self-sampling, their prior cervical screening status (under-screened or never-screened), clinical outcomes and participation in follow-up pathways of care, and satisfaction with the service model.

RESULTS

In total, 215 women conducted a HPV self-sampling test and 200 evaluation surveys were completed. One-fifth of participants (n = 46) were never-screened and one-third (n = 69) were under-screened. Many were unsure of their screening status. Nine women were HPV 16/18 positive and eight had completed all follow up by the conclusion of the study. A further 30 women tested positive for a high risk type other than HPV 16/18 (HPV other), of which 14 had completed follow up at the conclusion of the study. Satisfaction with the HPV self-sampling kit, the process of self-sampling and the service model was high (> 92% satisfied on all items). Many women had difficulty understanding their official HPV results and placed high importance on the nurse explaining it to them.

CONCLUSIONS

A community-based service model that respects Aboriginal Women's Business can effectively recruit under-screened and never-screened Aboriginal women to complete cervical cancer screening. Furthermore, this service model supports them to complete recommended follow-up care and engage with their local existing health services.

Design and feasibility of a novel program of cervical screening in Nigeria: self-sampled HPV testing paired with visual triage

Background

Accelerated global control of cervical cancer would require primary prevention with human papillomavirus (HPV) vaccination in addition to novel screening program strategies that are simple, inexpensive, and effective. We present the feasibility and outcome of a community-based HPV self-sampled screening program.

Methods

In Ile Ife, Nigeria, 9406 women aged 30-49 years collected vaginal self-samples, which were tested for HPV in the local study laboratory using Hybrid Capture-2 (HC2) (Qiagen). HPV-positive women were referred to the colposcopy clinic. Gynecologist colposcopic impression dictated immediate management; biopsies were taken when definite acetowhitening was present to produce a histopathologic reference standard of precancer (and to determine final clinical management). Retrospective linkage to the medical records identified 442 of 9406 women living with HIV (WLWH).

Results

With self-sampling, it was possible to screen more than 100 women per day per clinic. Following an audio-visual presentation and in-person instructions, overall acceptability of self-sampling was very high (81.2% women preferring self-sampling over clinician collection). HPV positivity was found in 17.3% of women. Intensive follow-up contributed to 85.9% attendance at the colposcopy clinic. Of those referred, 8.2% were initially treated with thermal ablation and 5.6% with large loop excision of transformation zone (LLETZ). Full visibility of the squamocolumnar junction, necessary for optimal visual triage and ablation, declined from 68.5% at age 30 to 35.4% at age 49. CIN2+ and CIN3+ (CIN- Cervical intraepithelial neoplasia), including five cancers, were identified by histology in 5.9 and 3.2% of the HPV-positive women, respectively (0.9 and 0.5% of the total screening population), leading to additional treatment as indicated. The prevalences of HPV infection and CIN2+ were substantially higher (40.5 and 2.5%, respectively) among WLWH. Colposcopic impression led to over- and under-treatment compared to the histopathology reference standard.

Conclusion

A cervical cancer screening program using self-sampled HPV testing, with colposcopic immediate management of women positive for HPV, proved feasible in Nigeria. Based on the collected specimens and images, we are now evaluating the use of a combination of partial HPV typing and automated visual evaluation (AVE) of cervical images to improve the accuracy of the screening program.

Disparities in cervical screening participation: a comparison of Russian, Somali and Kurdish immigrants with the general Finnish population

Background

Cervical cancer is currently ranked as the fourth commonly diagnosed cancer in women globally. A higher incidence has been reported in low- and-middle-income countries, and the disease poses significant public health challenges. Evidence suggests that this disease is preventable by means of regular screening using the Papanicolaou (Pap) test. However, limited knowledge exists about disparities in cervical screening participation among immigrants compared with non-immigrants, in countries with universal cervical screening programmes. We aimed to examine disparities in cervical screening participation among women of Russian, Somali, and Kurdish, origin in Finland, comparing them with the general Finnish population (Finns). We controlled for differences in several socio-demographic and health-related variables as potential confounders.

Methods

We employed data from the Finnish Migrant Health and Well-being Study 2010–2012 and the National Health 2011 Survey. Data collection involved face-to-face interviews. Data on screening participation in the previous five years from women aged 29–60 were available from 537 immigrants (257 Russians, 113 Somalis, 167 Kurds) and from 436 Finns. For statistical analyses, we used multiple logistic regression.

Results

Age-adjusted screening participation rates were as follows: Russians 79% (95% CI 72.9–84.4), Somalis 41% (95% CI 31.4–50.1), and Kurds 64% (95% CI 57.2–70.8), compared with 94% (95% CI 91.4–95.9) among Finns. After additionally adjusting for socio-demographic and health-related confounders, all the immigrant groups showed a significantly lower likelihood of screening participation when compared with Finns. The Odds Ratios were as follows: Russians 0.32 (95% CI 0.18–0.58), Somalis 0.10 (95% CI 0.04–0.23), and Kurds 0.17 (95% CI 0.09–0.35). However, when additionally accounting for country of origin-confounder interactions, such differences were attenuated.

Conclusions

Our results indicate disparities in screening participation among these immigrants and a lower likelihood of screening participation compared with the general Finnish population. To improve equity in cervical cancer screening participation, appropriate culturally tailored intervention programmes for each immigrant group might be beneficial.

How confident can we be in the current guidelines for exiting cervical screening?

Current US guidelines recommend against cervical screening beyond age 65 in women who have had adequate negative screening. In anticipation of the next round of evidence review and guideline updates, we provide a critical review of the evidence supporting the exiting recommendation in the US, highlighting both practice changes and new insights into the epidemiology and natural history of HPV and cervical cancer. Current recommendations are based, by necessity, on cytology alone, and will be limited in generalizability to evolving screening strategies with co-testing and primary HPV testing. The lack of empirical data to define what constitutes 'adequate recent screening with negative results' is compounded by difficulties in predicting future risk without consideration of concepts of HPV latency and cohort effects of changing sexual behaviour in US women over time. We urge caution in extrapolating past risk experience in post-menopausal women to today's population, and suggest study designs to strengthen the evidence base in well-screened older women. We further recommend building the qualitative evidence base to better define the harms and benefits of screening among older women. Extending the lifetime of screening is a matter of finding the appropriate balance of benefits of cancer reduction and limitation of harms and costs of 'overscreening'. This will require moving beyond current emphasis on number of colposcopies as the metric of harm. Our commentary is meant to stimulate intellectual debate regarding the certainty of our existing knowledge base and set clear research priorities for the future.

Follow-up of high-risk HPV positive women by combined cytology and bi-marker CADM1/MAL methylation analysis on cervical scrapes

OBJECTIVES

Triage of HPV screen-positive women is needed to identify those with underlying cervical intraepithelial neoplasia grade 2/3 or worse (CIN2/3+). Presently, cytology on a physician-taken cervical scrape is mostly accepted as triage test, but needs follow-up testing in order not to miss severe disease. Here, we evaluated the performance of combined cytology and bi-marker CADM1/MAL-methylation analysis as triage test on physician-taken cervical scrapes of HPV positive women.

METHODS

In this post-hoc analysis, we used 364 left-over HPV positive cytology triage samples of participants of a randomized controlled trial (PROHTECT-3: n=46,001) performed in population-based cervical screening. Study endpoints were CIN2+ and CIN3+ detection. Cytology testing with and without methylation marker analysis was evaluated with regard to sensitivity, specificity, positive and negative predictive value, and referral rate.

RESULTS

Bi-marker CADM1/MAL-methylation positivity increased proportionally with severity of underlying lesions. Overall, cytology and bi-marker CADM1/MAL-methylation analysis yielded similar performances with regard to CIN3+ detection, yet in combination a significantly higher sensitivity for CIN3+ (88.7%) was obtained at a specificity of 53.6% and a colposcopy referral rate of 53.6%. The combined strategy detected all six cervical cancers, whereas triage by cytology alone failed to detect two of them.

CONCLUSIONS

Cytology and bi-marker CADM1/MAL-methylation analysis perform complementary for CIN2+/CIN3+ detection when used as triage tool on cervical scrapes of HPV positive women. This approach not only results in a higher CIN3+ sensitivity than cytology triage with an acceptable referral rate, but also seems to reduce the risk of missing cervical cancers and advanced high-grade lesions.