A COMPARATIVE STUDY ON CERVICAL CANCER SCREENING METHOD: IS IMMUNO-MARKER A BETTER OPTION?

Cervical cytology by Papanicolaou (PAP) staining has been the backbone of primary screening of cervical cancer. For low resource countries, the major constraints in running a successful screening program are paucity of experienced personnel, requirement for multiple visits, economic considerations and inherent attributes of the test including a low sensitivity and specificity. The present study was designed to compare the efficacy of commonly available screening tests and feasibility of immuno-markers (p16 & Ki-67) as a primary screening tool. This was a cross-sectional analytical study. 100 patients were approached and agreed to participate in this study. They underwent cervical screening by multiple modalities including PAP smear, Liquid based cytology (LBC), HPV- DNA testing, cytology + HPV- DNA/p16/ Ki-67 and dual markers. Screening test results were compared with histopathology and statistical analysis done. The sensitivity and specificity of conventional cytology was 61.11% and 70%; LBC: 88.88% and 50%; Cytology + HPV DNA: 94.44% and 50%; Cytology + p16: 88.88% and 60%; Cytology + Ki-67: 88.88% and 100%; P16+Ki67: 88.88% and 60%. Combining Ki- 67 with Conventional cytology improved specificity and positive predictive value of cervical cancer screening.

Exploring Women’s Challenge to Pap Smear Attendance and Colposcopy Referral: A Qualitative Study

@#Introduction: The greatest protection against cervical cancer can be achieved through the combination of cervical screening via repeated Pap tests and HPV vaccination before first sexual intercourse. This study aimed to explore women’s perceptions and experiences of Pap test and colposcopy examination to avoid advance stage of cervical cancer. Methods: An exploratory qualitative approach was carried out using face-to face semi-structured interviews with 22 women attending for their Pap test appointment or colposcopy examination in the main hospital in Kirkuk, Iraq. The study took place between October 2019 and March 2020. The collected data were analysed using inductive content analysis. Results: The findings revealed gap in knowledge regarding Pap test and colposcopy investigation among participants. Overall, three main categories emerged during data analyses namely, women’s awareness of Pap test; challenges to access cervical screening and colposcopy services; women’s views and suggestions to improve their access to cervical screening cervices. Conclusion: Currently, women living in Iraq have no access to regular cervical screening due to unavailability of the cervical screening programme in Iraq. This study provides evidence to develop strategies to enhance the existing cervical cancer prevention services. Health policy makers should consider the establishment of regular population based cervical screening. Health promotion efforts and interventions should focus on challenges and barriers influence the screening behavior among women living in Iraq

The odds that working women will accept cervical cancer screening and HPV vaccination

Background: Factors influencing acceptance of cervical cancer services are being investigated, and widely reported to be quite low. However, there is dearth of research investigation on the odds of women’s acceptance of this gynaecological service. Objective of this study was to investigates the odds of unwilling to accept cervical cancer services.Methods: The study was a questionnaire-based cross-sectional survey and fourth piece in a series of analysis. Details of data collection are as previously described. Odds ratio was determined using online calculator; and based on proportion of respondents who have accepted the cervical cancer service, willing to complete an incomplete process and encourage others to take up the procedure.Results: The percentage of respondents who indicated no problem with HPV vaccination (55%) is higher than cervical screening (53%), but not statistically significantly different. On average, unwillingness to vaccinate later, complete their vaccinations or encourage their daughter are one-third of those who vaccinated. Those unwilling to take up cervical screening, encourage others to screen or overcome their fears are more than (161%) the subgroup who have been screened. Results show odds of unwillingness for both procedures are less than 1, but a little greater for cervical screening.Conclusions: It has been articulated that the likelihood to take up cervical cancer services will be influenced by the beliefs. This report advances that observed low acceptance level does not translate to high likelihood of unwillingness to accept the gynaecological services. Belief and nature of work of women need to be concertedly investigated.

Demographics and knowledge of cervical cancer of female civil servants in Delta State on Nigeria

Background: Delta state of Nigeria is a typical micro-world of multicultural values and religious beliefs as well as socioeconomic strata that could impact on the uptake of cervical cancer screening and HPV vaccination. Yet, the demographics of women in conjunction with knowledge and perception of cervical cancer screening have not been surveyed. This study aimed to assess the demographics of civil service women servants in Delta State and their knowledge regarding cervical cancer.Methods: The study was a questionnaire-based cross-sectional survey of female civil servants in the states’ capital city of Asaba. Structured questionnaire was used to collect data on eight demographic factors (age, educational level, ethnicity, income level, marital status, number of children, religion and workplace); as well as information on knowledge of cervical. Percentage proportions of respondents were assessed for the eight demographic factors. Absolute frequencies of affirmative responses to the questions on knowledge were evaluation. Hypothesis was tested for statistical significance of the demographic variables.Results: Analysis of the respondents (N=285) show that virtually all participants have heard of cervical cancer and knows that sexual promiscuity is a risk of the health condition. Only less than 5% of them attribute healthcare workers as their source of knowledge. Except age and marital status, every demographic variable is significant (p<0.05).Conclusions: Demographics of women are significant in terms of potential factors that could influence the uptake of HPV vaccination and cervical cancer screening.

Cervical cancer screening and prevention: how aware is the Indian woman?

Background: Carcinoma of the cervix is the second most common cancer in women worldwide. It is the commonest cancer among Indian women. Awareness regarding cervical cancer and its prevention is quite low amongst Indian women. The Pap test is a simple and cost-effective technique for early diagnosis of cervical cancer.Methods: It was a cross sectional study conducted in the months of September and October 2018. We included 200 women between 30 and 60 years of age.Results: In present study, out of 200 respondents, 160 (80%) respondents got married after 21 years of age while 40 (20%) respondents got married below 21 years of age. 148 (74%) respondents had 2 children, 30 (15%) respondents had one child while 22 (11%) respondents had 3 children. 166 (83%) had heard about cervical cancer, 24 (12%) knew that cervical cancer can be cured if detected in early stage while only 10 (5%) knew that it can be prevented. 54 (27%) respondents knew that pap smear test should be done as screening test to detect cervical cancer in early stage while 22 (11%) respondents knew about HPV vaccine as preventive measure.Conclusions: In present study, though women have heard about cervical cancer, proper knowledge was very less. Also, awareness about HPV vaccine and Pap smear was less. There is need for proper information and facilities for pap smear and HPV vaccination.

Nuevas estrategias de prevención y control de cáncer de cuello uterino en Chile / New strategies for the prevention and control of cervical cancer in Chile

Resumen: Objetivos: Discutir el cáncer cervicouterino (CC), el virus del papiloma humano (VPH), el programa de control del CC y proponer alternativas para Chile. Material y métodos: Se analiza el programa nacional del CC 1966-2015 y la guía clínica 2015-2020, la prevalencia de VPH en mujeres y en casos de CC; la infección y serología de VPH; la autotoma; la precisión y rentabilidad del tamizaje con VPH contra el Papanicolaou y las opciones de triaje en VPH AR positivas. Resultados: En Chile mueren 600 mujeres (principalmente de bajos recursos) al año por CC. La cobertura del Papanicolaou es < 70%, sensibilidad muy inferior al test de VPH, por lo que el cambio es rentable. Desde 2015 se vacuna contra VPH a niñas menores de 13 años. Conclusiones: Las condiciones técnicas y económicas existen en Chile para lograr una mejoría sustancial del CC: se sugiere el reemplazo del Papanicolaou por el examen de VPH; tamizaje cada cinco años con opción de autotoma; triaje con base en la tipificación de VPH 16/18 o Papanicolaou.

Abstract: Objective: To discuss cervical cancer (CC), Human Papilloma Virus (HPV), CC control program and propose alternatives for Chile. Materials and methods: We analyzed the national program of CC 1966-2015 and the clinical CC guideline 2015-2020; HPV prevalence in women and in cases of CC; HPV infection and serology; the self-vaginal sample; the accuracy and cost-effectiveness of screening with HPV versus Papanicolaou, and triage options among HPV-AR positives. Results: 600 women die of CC each year in Chile, mainly from low resources. Papanicolaou coverage is <70%; Papanicolaou sensitivity is much lower than HPV test. Change from Papanicolaou to HPV test is cost-effective. Since 2015, girls under 13 have been vaccinated against HPV. Conclusions: There are the technical and economic conditions for a substantial improvement of CC in Chile: replacement of the Papanicolaou by HPV; screening every five years, with the option of self-sampling, and triage based on HPV 16/18 or Papanicolaou typing.

Risk stratification of type-specific human papillomavirus for cervical precancers: evidence from a cross-sectional study in Shenzhen / 中华肿瘤杂志

Objective@#To analyze the epidemiological genotype features of human papillomavirus (HPV) in cervical infection and their risks for cervical precancers among women in Shenzhen area.@*Methods@#A total of 2 717 individuals ranging in age from 30~59 years were recruited in 18 community health centers of Shenzhen city from March 1 to June 15, 2015 by a cluster sampling method. The results of genotype of HPV, liquid-based cytology (LBC), colposcopy and pathology were analyzed. The clinical sensitivity and specificity as well as positive (PPV) and negative (NPV) predictive values of the combination of different HPV genotype in screening the cervical intraepithelial neoplasia (CIN) 2 and above were estimated.@*Results@#The HPV infection rate in Shenzhen area was 15.9% (432/2 717). The most common HPV genotype was HPV52 (22.9%), followed by HPV16 (12.7%), HPV53 (10.0%), HPV51 (8.6%) and HPV58 (8.1%). Compared with HPV16/18 genotyping, HPV33/16 genotyping had a higher sensitivity (57.1% vs. 42.9%, P<0.05) and an analogous specificity (87.3% vs. 86.9%, P>0.05) in predicting CIN2+ . The sensitivity of combination of HPV33/16 genotyping and low grade squamous intraepithelial lesion (LSIL) positive tested by LBC in predicting CIN2+ was 75.0%, significantly higher than 64.3% of atypical squamous cells of undetermined significance (ASC-US) positive tested by LBC alone (P<0.05). The specificities of these two methods mentioned above in predicting CIN2+ were 83.5% and 89.2%, respectively, without statistical difference (P>0.05).@*Conclusions@#Women infected by HPV have distinct risks for CIN2+ according to different high-risk HPV genotypes. The top five risks were HPV 33, 16, 58, 56, and 68. HPV-positive women triaged by LBC LSIL+ combined with HPV33/16 genotyping may be a potential strategy for cervical cancer screening in developed urban area.

Performance of combined liquid based cytology and HPV nucleic acid test for detecting cervical precancer among women attending screening / 中华肿瘤杂志

Objective@#To evaluate the clinical performance of HPV genotyping with cytology for detecting cervical precancer among women attending co-testing.@*Methods@#A total of 2 883 females who participated in cervical cancer screening program were recruited from Erdos in 2016. All the participants were tested by cytology and HPV genotyping. In 2017, women with abnormal cytology results or HPV positive were followed up. Pathological cervical intraepithelial neoplasia (CIN) 2+ was the study end-point. Clinical performance indexes were calculated, including sensitivity, specificity, positive predictive value, negative predictive value, referral rate and missed cases.@*Results@#INNO-LiPA resulted in a detection rate of 18.87%(544/2 883) for the 14-type high risk HPV. HPV16 was the most common infectious genotype (4.06%), followed by HPV52 (3.61%), HPV51 (2.50%), HPV58 (1.98%), and HPV18 (1.56%). With more HPV genotypes added into the group, sensitivity increased and the specificity decreased. Addition of HPV16, 58, 33, 39, 52, 18, 31 for detection lead to the maximun value of area under the curve (AUC)=0.913 (95%CI: 0.882-0.944). Compared with traditional screening method by cytology, cotesting decreased the number of missed diagnosis. Meanwhile, the fifth method (co-testing: triage of women with HPV16/18+ , cytological minor abnormalities and HPV58, 33, 39, 52, 31+ or cytological high grade abnormalities) did not increase referral rate (8.99% vs. 8.71%, P=0.525), with five cases of missed diagnosis (sensitivity of 92.1% and specificity of 93.2%).@*Conclusions@#Co-testing with triage of women with HPV16/18+ , cytological minor abnormalities and HPV58, 33, 39, 52, 31+ or cytological high grade abnormalities would provide better clinical performance. In co-testing, triage of HPV16/18 was used in women with normal cytology; triage of HPV58, 33, 39, 52 and 31 was used in women with low-grade abnormal cytology; referral colposcopy was used in women with high-grade abnormal cytology, which would provide better clinical performance.

Cervical HPV Infection in Indian Women: Screening and Immunization as Preventive Strategies.

Invasive cervical cancer (ICC) is the second leading cause of cancer related mortality among women in India. Human papillomavirus (HPV), the etiological agent of cervical cancer is widely prevalent worldwide. Persistent HPV infection, particularly with HPV 16, is essential for progression to cervical cancer. Human papillomavirus 16 and 18 are the most common genotypes detected among Indian HIV-infected and uninfected women, although their relative contributions vary. HIV-infected Indian women experience a higher risk for HPV infection compared to the general population. Although cervical screening and vaccination to protect against HPV infection are the two main strategies for prevention, there are significant challenges to their implementation in India. Scaling up of cervical screening using simple, rapid tests followed by colposcopy and treatment within a minimal number of visits is essential to prevent loss to followup. Increasing the uptake of the HPV vaccine combined with cervical screening can greatly reduce the burden of ICC in India.

Detección de virus papiloma humano en la prevención del cáncer cérvico-uterino / Human papilomavirus detection in cervical cancer prevention

El cáncer cérvico-uterino (CCU), que está fuertemente asociado a la infección por virus papiloma humano de alto riesgo (VPH-AR), sigue siendo un problema de salud pública en Latinoamérica. El uso de la citología para la detección de lesiones pre-cancerosas no ha tenido mayor impacto en las tasas de incidencia y mortalidad del CCU, que aún se mantienen altas en la región. La disponibilidad de nuevas técnicas de tamizaje para la detección de lesiones pre-cancerosas y de vacunas altamente eficaces que previenen casi todas las lesiones relacionadas con los VPH-AR de alto potencial oncogénico VPH 16 y 18, en mujeres no expuestas previamente al virus brindan una gran oportunidad para la prevención del CCU. La detección de VPH-AR representa actualmente un valioso componente de las guías clínicas para el tamizaje, manejo y tratamiento del CCU y sus lesiones precursoras. Se han desarrollado estrategias metodológicas que detectan un amplio espectro de tipos de VPH-AR; sin embargo, solo un pequeño subgrupo de ellas ha documentado la validación clínica para cualquiera de las indicaciones habituales de la detección de estos virus. Las pruebas de VPH que no estén validadas y que no hayan demostrado confiabilidad, reproducibilidad y exactitud no deben ser usadas en el manejo clínico. Una vez incorporada una prueba de VPH en el laboratorio, es esencial que el procedimiento completo sea sometido a un continuo y riguroso control de calidad para evitar prácticas subóptimas, potencialmente dañinas. Este artículo discute los recientes progresos y el estado actual de estos métodos.

Cervical cancer (CC), which is strongly associated to high-risk human papillomavirus (hr-HPV) infection, continues being a significant health problem in Latin America. The use of conventional cytology to detect precancerous cervical lesions has had no major impact on reducing CC incidence and mortality rates, which are still high in the region. New screening tools to detect precancerous lesions became available, which provide great opportunities for CC prevention, as do highly efficacious HPV vaccines able to prevent nearly all lesions associated with HPV-16 and -18 when applied before viral exposure. Currently, hr-HPV testing represents an invaluable component of clinical guidelines for screening, management and treatment of CC and their precursor lesions. Many testing strategies have been developed that can detect a broad spectrum of hr-HPV types in a single assay; however, only a small subset of them has documented clinical performance for any of the standard HPV testing indications. HPV tests that have not been validated and lack proof of reliability, reproducibility and accuracy should not be used in clinical management. Once incorporated into the lab, it is essential to submit the whole procedure of HPV testing to continuous and rigorous quality assurance to avoid sub-optimal, potentially harmful practices. Recent progress and current status of these methods are discussed in this article.

HPV vaginal self-sampling among women non-adherent to Papanicolaou screening in Chile / Autotoma vaginal para detección de virus del papiloma humano en mujeres no adherentes a tamizaje con Papanicolaou en Chile

OBJECTIVE: To evaluate acceptance, preference and compliance with referral of vaginal self-sampling for the detection of Human papillomavirus (HPV) among women non-adherent to Papanicolaou (Pap) screening in Santiago, Chile. MATERIALS AND METHODS: Using multistage sampling we identified women aged 30-64 years who reported not receiving a Pap test in the previous three years and offered them Pap testing at the health center or vaginal self-sampling for HPV testing at home. Self-collected samples were analyzed with hybrid capture. All HPV+ women were referred for colposcopy, biopsy and treatment when needed. RESULTS: 1 254 eligible women were contacted; 86.5% performed self-sampling and 8.1% refused; 124 women were HPV+ (11.4%: 95%CI 9.6-13.5) of whom 85.5% attended colposcopy; 12 had CIN2+ (1.1%: 95 %CI 0.5-1.7). CONCLUSION: HPV vaginal self-sampling can be easily implemented in Chile and could improve coverage, successfully reaching women who drop out of the screening program.

OBJETIVO: Evaluar la aceptación, preferencia y adherencia a seguimiento de la autotoma vaginal para detección del virus del papiloma humano (VPH) en mujeres inasistentes a Papanicolaou (Pap) en Santiago, Chile. MATERIAL Y MÉTODOS: Mediante un muestreo polietápico se identificaron mujeres entre 30 y 64 años inasistentes a Pap por < 3 años, invitándolas a realizarse un Pap en su centro de salud o una autotoma vaginal a domicilio. Las muestras fueron analizadas con captura de híbridos. Las mujeres VPH+ fueron referidas a colposcopía, biopsia y tratamiento en caso necesario. RESULTADOS: 1 254 mujeres elegibles fueron contactadas; 86.5% aceptó la autotoma vaginal y 8.1% la rechazó; 124 mujeres resultaron VPH+ (11.4%: IC95% 9.6-13.5) de las que 85.5% asistió a colposcopía; 12 tenían CIN2+ (1.1%: IC95% 0.5-1.7). CONCLUSIÓN: La autotoma vaginal para detección de VPH es implementable en Chile y su utilización podría mejorar la cobertura del programa rescatando a mujeres inasistentes.

Significance of the high-risk human papilloma virus detection in the screening and diagnosis of cervical lesions / 中国医师进修杂志

[Objective]To investigate the significance of the high-risk human papilloma virus (HPV)detection in the screening and diagnosis of cervical lesions.[Methods] The high-risk HPV DNA test results of 797 patients with cervical lesions who all accepted cytology and histopathology test were collected and analyzed retrospectively.[Results]The high-risk HPV DNA positive rates in cervicitis,cervical intraepithelial neoplasia(CIN)Ⅰ,CIN Ⅱ,CIN Ⅲ and cervical cancer were 53.41％(188/352),70.91％(117/165),87.63％(85/97),97.90％(140/143),97.50％(39/40),respectively.The sensitivity and negative predictive value of the high-risk HPV DNA detection for CIN Ⅱ and more serious lesions were 96.66％(318/329),93.29％(153/164),respectively.The detection rate of CIN Ⅱ and more serious lesions in patients with atypical squamous cells of undetermined significance(ASCUS)and positive high-risk HPV DNA was 30.03％(94/313),while the rate in patients with negative high-risk HPV DNA was 1.55％(2/129).[Conclusions] The more serious the cervical lesion is,the higher high-risk HPV DNA positive rate is.It is most closely related with CIN 11 and cervical cancer.The high-risk HPV DNA detection has high sensitivity and negative predictive value for CIN Ⅱ and more serious lesions.The high-risk HPV DNA detection has high negative predictive value in CIN Ⅱ and more serious lesions in ASCUS.

Nuevos paradigmas y desafíos en la prevención y control del cáncer de cuello uterino en América Latina / New paradigms and challenges in cervical cancer prevention and control in Latin America

El cáncer de cuello uterino sigue siendo un problema de salud pública en Latinoamérica. El uso de la citología para la detección de lesiones pre-cancerosas no ha tenido mayor impacto en las tasas de incidencia y mortalidad, que aún se mantienen altas en la región. La disponibilidad de nuevas técnicas de tamizaje para la detección de lesiones pre-cancerosas y de vacunas altamente eficaces que previenen casi todas las lesiones relacionadas con VPH-16 y VPH-18 en mujeres no expuestas previamente al virus representan una gran oportunidad para la prevención del cáncer de cuello uterino en la región. En este manuscrito resumimos la evidencia científica y la experiencia de la región en i) el uso de pruebas de VPH y de la inspección visual después del ácido acético (IVAA) en tamizaje primario, y ii) la implementación de programas de vacunación en adolescentes. Finalmente enumeramos una serie de recomendaciones adecuadas para distintos escenarios. La factibilidad de implementar un programa nacional de prevención de cáncer de cuello uterino exitoso y sostenible en países latinoamericanos dependerá de las prioridades de salud, la infraestructura y personal de salud disponible, determinadas luego de un riguroso análisis situacional local.

Cervical cancer continues to be a significant health problem in Latin America. The use of conventional cytology to detect precancerous cervical lesions has had almost no major impact on reducing cervical cancer incidence and mortality rates, which are still high in the region. The availability of new screening tools to detect precancerous lesions provide great opportunities for cervical cancer prevention in the region, as do highly efficacious HPV vaccines able to prevent nearly all lesions associated with HPV-16 and -18 when applied before viral exposure. This paper summarizes the scientific evidence and regional experiences related to: i) the use of HPV testing and visual inspection after the application of acetic acid (VIA) in primary screening and ii) the implementation of adolescent HPV vaccination programs. Finally, we outline a number of recommendations for different resource settings. The feasibility of implementing successful and sustainable national cervical cancer prevention programs in Latin American countries in the region will depend on health priorities and the availability of infrastructure and health personnel-as determined by rigorous local situational analysis.

Relación costo-efectividad de las intervenciones preventivas contra el cáncer cervical en mujeres mexicanas / Generalized cost-effectiveness of preventive interventions against cervical cancer in Mexican women: results of a Markov model from the public sector perspective

OBJETIVO: Realizar un análisis de la relación costo-efectividad generalizada (ACEG) para la vacuna anti-VPH, el tamiz por captura de híbridos (CH) y el tamiz por Papanicolaou en el caso mexicano. MATERIAL Y MÉTODOS: Entre abril y agosto de 2007 se desarrolló en México un ACEG de las intervenciones relacionadas con 10 posibles escenarios en un modelo markoviano, bajo la perspectiva del sector público como pagador. RESULTADOS: Los escenarios con cobertura universal muestran un cociente costo-efectividad por AVISA ganado para el Papanicolaou en mujeres de 25 a 64 años de 16 678 pesos, para el tamiz por CH en mujeres de 30 a 64 años de 17 285 pesos y para la vacuna en niñas de 12 años de 84 008 pesos. El financiamiento anual necesario para estas intervenciones es de 621, 741 y 2 255 millones de pesos, respectivamente. CONCLUSIONES: Se sugiere introducir una combinación selectiva de tamices (Papanicolaou y CH) y considerar las ventajas comparativas de aplicación en distintas poblaciones y áreas geográficas. De manera complementaria, se aconseja introducir la vacuna con un precio umbral de 181 pesos por dosis, equiparable en términos del costo y la efectividad a la CH.

OBJECTIVE: To develop a generalized cost-effectiveness analysis (GCEA) of the HPV vaccine, hybrid capture screening (HC) and Papanicolaou screening (Pap) in the Mexican context. MATERIALS AND METHODS: From April to August 2007, in Mexico, a GCEA of the interventions was developed for 10 possible scenarios using a Markov model from the public sector perspective as payer. RESULTS: Scenarios considering 80 percent coverage show an ACER per DALY averted of $16678 pesos for Pap of women between ages 25 and 64, $17277 pesos for HC of women between ages 30 and 64, and $84008 pesos for vaccination of 12-year-old girls. Annual financing of $621, $741 and $2255 million pesos, respectively, is needed for these scenarios. CONCLUSIONS: A selective, combined introduction of Pap-HC screening that considers the comparative advantages of application in different populations and geographical areas is suggested. Additionally, it is suggested to introduce the vaccine once a threshold price of $181 pesos per dose -when the vaccine becomes equal in terms of cost-effectiveness to HC- has been achieved.