Tamización primaria con prueba ADN-VPH en mujeres menores de 30 años: evaluación de tecnología sanitaria / Primary HPV-DNA screening in women under 30 years of age: health technology assessment

Antecedentes A partir del 2014 en Colombia se incorporó la Tamización primaria con prueba de Virus del Papiloma Humano (VPH) desde los 30 hasta los 65 años, cuando la prueba es positiva se hace triage con citología para remisión a colposcopia. Actualmente se discute la conveniencia de iniciar la tamización con prueba de ADN de VPH a partir de los 25 años. De esta manera, el objetivo de esta evaluación de tecnologías sanitarias es analizar la evidencia disponible en torno a la seguridad, efectividad, costoefectividad, valores y preferencias, dilemas éticos y aspectos relacionados con la implementación para el contexto colombiano de la prueba ADN-VPH como estrategia de tamización cervical en mujeres menores de 30 años. Dominios a evaluar Eficacia clínica y seguridad 1. Tasa acumulada de neoplasia intraepitelial cervical (NIC) grado 2 o más avanzado luego de 2 rondas de tamización. 2. Tasas acumuladas de cáncer invasor de cérvix luego de 2 rondas de tamización. 3. Seguridad: remisión a colposcopia. Costo-efectividad Costo efectividad para Colombia. Otros dominios considerados Aspectos éticos asociados a la tamización cervical en mujeres menores de 30 años. Aspectos organizacionales y del individuo. Barreras y facilitadores relacionados con la implementación en el contexto colombiano de la tamización cervical en mujeres menores de 30 años. Métodos Evaluación de efectividad y seguridad clínicas Se realizó una búsqueda sistemática de la literatura en MEDLINE, Embase y CENTRAL de revisiones sistemáticas y ensayos clínicos. Se calificó el cuerpo de la evidencia con la aproximación GRADE. Posteriormente, se convocó a un grupo interdisciplinario a una mesa de trabajo en donde se presentó la evidencia recuperada, dando paso a la discusión y a la construcción de las conclusiones, siguiendo los lineamientos de un consenso formal acorde a la metodología RAND/UCLA. Estudio económico Se hizo una búsqueda sistemática de la literatura de estudios que hubieran evaluado el costo-efectividad para Colombia. Resultados De 7.659 referencias recuperadas se incluyeron 8 estudios. Resultados clínicos Se realizó un análisis integrativo de 5 ensayos clínicos aleatorizados que cumplieron con los citerios de inclusión. Cuando se compara frente a la citología, la tamización primaria con ADN-VPH en mujeres menores de 30 años, podría asociarse con una mayor frecuencia de detección de lesiones NIC2+ durante la primera ronda de cribado (RR: 1.57; IC: 1,20 a 2,04; certeza en la evidencia baja), con una menor incidencia de NIC2+ (RR:0,67; IC: 0,48 a 0,92; certeza en la evidencia baja) y se asocia con una menor frecuencia de carcinoma invasor al término del seguimiento (RR: 0,19; IC: 0,07 a 0,53; certeza en la evidencia alta). Resultados económicos Desde el punto de vista económico, la alternativa de ADN-VPH y triage con citología desde los 25 años quizás representa la alternativa más costo-efectiva para Colombia (razón costo-efectividad incremental $8.820.980 COP año 2013). Otras implicaciones Dos estudios sugieren que las barreras de implementación, atribuibles a circunstancias de intermediación, de orden público y de carácter geográfico, podrían ser solventadas por nuevas tecnologías o estrategias de cribado. Es importante considerar alternativas de forma de administración y de prestación de servicios para solventar algunas barreras de aceptabilidad y acceso. Todo programa de tamización cervical debe contemplar los principios éticos de no maleficencia, beneficencia, autonomía y equidad. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años. Conclusiones El uso de la prueba ADN-VPH como estrategia de tamización en mujeres menores de 30 años es una intervención probablemente efectiva y costoefectiva para Colombia. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años.

Background Primary screening with Human Papilloma Virus (HPV) testing was introduced in Colombia in 2014 for individuals between 30 and 65 years of age. When the result is positive, cytology triage is performed for colposcopy referral. The convenience of initiating HPV-DNA testing for screening at 25 years of age is currently a subject of discussion. Therefore, the objective of this health technology assessment (HTA) is to analyze the available evidence regarding safety, efficacy, cost-effectiveness, values and preferences, ethical dilemmas and considerations pertaining to the implementation of the HPV-DNA test as a cervical screening strategy in women under 30 years of age in the Colombian context. Domains to be assessed Clinical efficacy and safety 1. Cumulative rate of cervical intraepithelial neoplasia (CIN) grade 2 or high-er after 2 screening rounds. 2. Cumulative rates of invasive cancer of the uterine cervix after 2 screening rounds. 3. Safety: referral to colposcopy Cost-effectiveness Cost-effectiveness for Colombia. Other domains considered Ethical considerations associated with cervical screening in women under 30 years of age. Organizational and individual considerations. Barriers and facilitators pertaining to the implementation of cervical screening in women under 30 years of age in the Colombian context. Methods Clinical efficacy and safety assessment A systematic literature search of systematic reviews and clinical trials was conducted in MEDLINE, Embase and CENTRAL. The body of evidence was rated using the GRADE approach. An interdisciplinary team was then convened to create a working group to review the retrieved evidence. This led to the discussion and construction of the conclusions following the guidelines of a formal consensus in accordance with the RAND/UCLA methodology. Economic study Systematic literature research of studies that had assessed cost-effectiveness for Colombia. Results Out of the 7,659 references retrieved, 8 studies were included. Clinical outcomes An integrative analysis of 5 randomized clinical trials that met the inclusion critera was performed. Compared with cytology, primary HPV-DNA testing in women under 30 years of age could be associated with a lower frequency of CIN+2 lesions during the first screening round (RR: 1.57; CI: 1.20 to 2.04; low evidence certainty), and a lower incidence of CIN+2 (RR: 0.67; CI: 0.48 to 0.92; low evidence certainty). Moreover, it is associated with a lower frequency of invasive carcinoma at the end of follow-up (RR: 0.19; CI: 0.07 to 0.53; high evidence certainty). Economic results From the financial point of view, the use of HPVDNA testing plus cytology-based triage starting at 25 years of age is perhaps the most cost-effective option for Colombia (incremental cost-effectiveness ratio, COP 8,820,980 in 2013). Other implications Two studies suggest that barriers to implementation attributable to intermediation, public unrest and geographic considerations could be overcome with the use of new screening technologies or strategies. It is important to consider administration and service provision alternatives in order to overcome some acceptability and access barriers. Any cervical screening program must take into consideration ethical principles of nonmaleficence, beneficence, autonomy and equity. Future studies should focus on analyzing new screening techniques with emphasis on the population under 30 years of age. Conclusions The use of HPV-DNA testing as a screening strategy in women under 30 years of age is a potentially efficacious and cost-effective intervention for Colombia. Future studies should focus on analyzing new screening technologies, with emphasis on the population under 30 years of age.

Total body mapping in the follow-up of melanocytic lesions: recommendations of the Brazilian Society of Dermatology

Abstract Total body mapping comprises photographic documentation of the entire body surface followed by digital dermatoscopy of selected melanocytic lesions, aiming to compare their evolution over time and identify new lesions. As this is an exam based on comparative analysis of serial dermoscopic body images, standardization of the technique for performing total body mapping is essential. Prepared by specialists from the Brazilian Society of Dermatology, using the modified Delphi method, this article provides recommendations for carrying out total body mapping in Brazil, regarding its indications, technical aspects, and the issuing of the report.

Análisis de los métodos de detección de lesiones orales potencialmente malignas. Revisión sistemática tipo paraguas / Analysis of the detection methods for potentially malignant oral lesions. An umbrella systematic review

Resumen Propósito: determinar la efectividad de detección de lesiones orales potencialmente malignas de cuatro métodos por medio de revisión sistemática tipo paraguas. Fuente de los datos: la búsqueda fue realizada con bases de datos Pubmed y EBSCOhost. Restricción de los años 2013-2018. Estrategia de búsqueda: (early detection of cáncer) AND (mouth neoplasms), (early detection of cáncer) AND (diagnostic techniques and procedures), (mouth neoplasms) AND (diagnostic techniques and procedures). Selección de los estudios: fueron seleccionadas a través de lectura crítica y la lista de chequeo del formato PRISMA, aquellas revisiones sistemáticas cuyo objetivo sea evaluar la efectividad de al menos uno de los métodos de detección de lesiones orales potencialmente malignas, seis estudios cumplieron con los criterios de inclusión. Extracción de datos: mediante la realización de lectura crítica de las revisiones sistemáticas seleccionadas previamente. Resultado de síntesis de los datos: se determina la efectividad a través de la comparación de las medias de porcentajes de sensibilidad y especificidad. Las medias de sensibilidad y especificidad de Vizilite fueron de 81.31 y 25.4%, de Microlux DL de 82.63 y 69.52%, de azul de toluidina de 82.07 y 66.27% y de citología exfoliativa de 76.77 y 80.87%, respectivamente. Conclusiones: los métodos de detección de lesiones orales premalignas evaluados en el presente estudio requieren mayor respaldo de evidencia científica para validar su efectividad. El método con mayor eficacia es el Microlux/DL, debido a sus altos niveles de sensibilidad y especificidad.

Abstract Objective: to determine the effectiveness of four methods for detecting potentially malignant oral lesions through an umbrella systematic review. Source of data: the search was performed in the PubMed and EBSCOhost databases. Years of search limited to 2013-2018. Search strategy: (early detection of cancer) AND (mouth neoplasms), (early detection of cancer) AND (diagnostic techniques and procedures), (mouth neoplasms) AND (diagnostic techniques and procedures). Study selection: using critical reading and the PRISMA checklist, systematic reviews with the objective of evaluating the effectiveness of at least one of the detection methods for potentially malignant oral lesions were selected; six studies met the inclusion criteria. Data extraction: through critical reading of the previously selected systematic reviews. Results of data synthesis: effectiveness was determined by comparing the mean percentages of sensitivity and specificity. Vizilite's sensitivity and specificity means were 81.31 and 25.4%, Microlux DL's were 82.63 and 69.52%, toluidine blue's were 82.07 and 66.27%, and exfoliative cytology's were 76.77 and 80.87%, respectively. Conclusions: the detection methods for pre-malignant oral lesions evaluated in this study need greater scientific evidence to validate their effectiveness. The method with the greatest effectiveness is Microlux/DL, due to its high levels of sensitivity and specificity.

Evaluation of breast cancer in women under 50 in a Mastology service in the Federal District, Brazil

Introduction: Breast cancer is a relevant public health issue, and its incidence has increased in patients aged less than 50 years. This population usually receives a late diagnosis, which contributes with the poor prognosis of the condition. Objective: To assess the percentage of patients diagnosed with breast cancer before the age of 50 and compare them with the group that was diagnosed after the age of 50. Results: The general mean age was 54 years; 75.68% of the patients were younger than 50 years, aged between 40 and 49 years. Among the ones who were younger than 50, 35.14% were in stage T4; 55.41% underwent neoadjuvant chemotherapy; 16.22% presented distant metastasis; and 10.81%, locoregional metastasis. On the other hand, among those aged more than 50, 22.71% were in stage T4; 30.68% underwent neoadjuvant chemotherapy; 11.36% presented distant metastasis; and 6.82%, locoregional metastasis. Conclusion: Breast cancer in women aged less than 50 years in a Mastology service in the Federal District has been a matter of concern, for presenting more advanced tumors at the time of diagnosis; screening is still debatable.

Retinoblastoma in Mexico: part I. A review of general knowledge of the disease, diagnosis, and management / Retinoblastoma en México: parte I. Revisión del conocimiento general de la enfermedad, diagnóstico y tratamiento

AbstractThis is the first of a two-part review that aims to report the current knowledge of retinoblastoma (Rb) and its implications in Mexico (including the authors' experience at the leading Rb centers), identify the gaps in practice, and propose solutions to improve diagnosis, treatment, and patient uptake. In this first part, general knowledge of Rb diagnosis and management is summarized with a focus on the latest advances in chemotherapy. A general review of peer-reviewed literature of Rb was conducted on PubMed. Key findings were summarized.Provided there is early detection and referral of patients followed by appropriate conservative management, Rb is curable. In developed countries, the primary treatment outcome is ocular salvage with sight preservation. Advanced chemotherapeutic options such as intra-arterial and intravitreal chemotherapy can now save even the most advanced tumors.Advances in Rb therapy are generally limited to developed countries. The implications in Mexico, of the findings from this review will be discussed in Part 2, which will be a comprehensive situational analysis of the state of Rb programming in Mexico, including a review of current demographic data available from hospitals that have Rb programs or treat Rb.

ResumenEsta es la primera parte de un trabajo de revisión donde se reportan los conocimientos actuales del retinoblastoma (Rb) y sus implicaciones en México (incluyendo la experiencia de los autores en los principales centros de referencia), así como las brechas en la práctica y las posibles soluciones para mejorar el diagnóstico, tratamiento y referencia de pacientes. En esta parte se resumen los conocimientos generales del Rb, su diagnóstico y tratamiento. Se realizó una revisión de los avances más recientes en esta enfermedad publicados en PubMed y se resumieron los hallazgos más importantes.La sospecha oportuna y la referencia adecuada de pacientes permiten que el tratamiento conservador del Rb sea curativo. En países en vías de desarrollo, el tratamiento primario es el salvamento ocular y la preservación de la visión. Las opciones de quimioterapia intraarterial o intravítrea permiten ofrecer opciones terapéuticas en estos pacientes.Los avances en el tratamiento del Rb están generalmente limitados a países industrializados. Las implicaciones de los hallazgos de esta revisión serán discutidas en la segunda parte, la cual será un análisis de la situación de los programas hospitalarios del Rb en México, incluyendo la revisión de los datos demográficos disponibles de los centros de referencia más importantes.

Persons with disabilities, cancer screening and related factors / Pessoas com deficiência, exames preventivos de câncer e fatores relacionados

The scope of this article is to describe persons with disabilities (PwD) being subjected to cancer screening and the relationship between some social variables and inequalities in performing these tests. A cross-sectional study of cancer screening among PwD was conducted in 2007 with 333 participants interviewed in residence in 4 cities of São Paulo. Variables in the practice of cancer screening, disabilities, gender, age, income of main family breadwinner, ethnicity, use of health services, assistance required, private health insurance, and coverage by the family health program were studied. Frequencies, χ²-test, trend χ² percentages and the Odds Ratios (OR) were used for data analysis. 44% of PwD attended at least one cancer screening at the appropriate time. Persons with visual disabilities and with hearing disabilities were subjected to more screening examinations than those with mobility disabilities and women were attended in screening exams more than men. Persons between the ages of 21 and 60 reported cancer screening more frequently than those between 80 and 97 years of age. The outcomes indicate that PwD have different attitudes toward cancer screening according to the type of disability, gender, and age, which were the variables that directly influenced cancer screening exams.

O objetivo deste artigo é descrever a realização de exames preventivos de câncer entre pessoas com deficiências (PD) e a relação entre algumas variáveis sociais e as desigualdades na realização dos exames. Estudo transversal sobre exames preventivos de câncer entre PD. Foram entrevistadas em domicílio 333 pessoas em quatro cidades de São Paulo, em 2007. Estudou-se variáveis relacionadas aos exames preventivos, deficiências, gênero, idade, renda do chefe da família, etnia, uso de serviços de saúde, assistência necessária, plano privado de saúde e cobertura pela Estratégia de Saúde da Família. Para a análise usou-se frequências, porcentagens, teste de χ², χ² de tendência e Odds Ratio (OR). Dos entrevistados, 44% realizou pelo menos um exame preventivo na época correta. Pessoas com deficiência visual e com deficiência auditiva fizeram mais exames do que aqueles com deficiência física. Mulheres fizeram mais exames que os homens e pessoas com idade entre 21 e 60 anos relataram maior frequência de exames que aquelas entre 80 e 97 anos. Os achados indicam que as PD tiveram diferentes padrões de realização de exames preventivos segundo o tipo de deficiência, gênero e idade, sendo estas as variáveis de influência direta na realização de exames preventivos de câncer.

Nanochips y nanosensores para eldiagnóstico temprano de cáncer oral: una revisión / Nanochips and nanosensors for harly oral cancer diagnosis: a review

Antecedentes: El cáncer oral es una de las enfermedades más agresivas y con mayor probabilidadde metástasis; en estadios iniciales es generalmente indetectable y de baja consulta,por lo que se dificulta realizar un tratamiento conservador. Existen diversas técnicas delaboratorio con base en microscopía (como inmunofluorescencia), inmunohistoquímica yotras que facilitan el diagnóstico temprano de la enfermedad. Adicionalmente, los avancesen nanomedicina brindan nuevas herramientas de detección a partir de cambios moleculares(biomarcadores) que presentan las células en proceso de malignización. Objetivo:Describir las características clínicas y moleculares de lesiones premalignas y cáncer oral ylos métodos de diagnóstico usando nanotecnología (nanochips, nanosensores, etc.), comoun método eficaz para la detección temprana del cáncer. Método: Se buscó literatura sobrenanotecnología y diagnóstico de cáncer oral en bases de datos como Science Direct yPubMed; la información de cada uno de los artículos se sintetizó con resúmenes individualespor los investigadores, se agrupó y redactó. Resultados: Se seleccionaron 46 artículos que,de acuerdo con su contenido, se agruparon según su temática principal; toda la informaciónse relacionó en una tabla por subtemas en Excel® 2007. Conclusiones: La literatura revisadasugiere que las herramientas nanotecnológicas pueden ser una alternativa útil y rápida,aunque por el momento costosa, para la detección puntual de biomarcadores presentes enestadios iniciales del cáncer oral. Cabe mencionar que su aplicación clínica en países comoColombia es limitada por factores como insuficientes recursos asignados a la investigacióny poca investigación en esta temática...

Background: Oral cancer is one of the most aggressive diseases with a high likelihood ofmetastases; it is undetectable during initial stages with low medical visits, making it difficultto provide conservative treatment. Several techniques such as microscopy (using for instanceimmunofluorescence) and immunohistochemistry make early diagnosis and cancerdetection easier. In addition, advances in nanomedicine offer new tools to detect molecularchanges (biological markers/biomarkers) in cells during a malignant process. Purpose:Describe molecular and clinic characteristics of premalignant lesions and oral cancer, aswell as techniques involving nanotechnology (lab-on-a-chip devices, nanosensors, etc.) aseffective methods for early cancer diagnosis. Methods: A literature review on nanotechnologyand oral cancer using databases such as Science Direct and PubMed was carried out;data from each article were summarized, grouped, and described. Results: 46 articles wereselected and grouped according to their main topic; data were compiled in an Excel 2007spreadsheet. Conclusions: The literature reviewed suggests that tools using nanotechnologycan be a useful and a quick alternative, though expensive, to detect specific biomarkers thatare present in early stages of oral cancer. It is important to point out that their clinical usein countries like Colombia is still limited by factors like the lack of resources allocated forresearch and the little research carried out on this subject...