Genotyping and follow-up of HR-HPV types detected by self-sampling in women from low socioeconomic groups not participating in regular cervical cancer screening in France.

BACKGROUND: HPV vaginal self-sampling can be an alternative for women refusing cytological screening. OBJECTIVES: To describe HR-HPV types in 35-69 years old women from low socioeconomic groups not attending regular cytological screening in Marseille, France. STUDY DESIGN: A cervical screening campaign using HR-HPV self-sampling including 22,702 women aged 35-69 years living in low socioeconomic districts of Marseille was organized. A cytological and/or histological follow-up was undertaken for a subset of women harboring HR-HPV types. Abbott RealTime High Risk HPV test was used for screening, while INNO-LiPA HPV Genotyping Extra assay was used for genotyping. RESULTS: 4245 self-samplings were performed (participation rate, 18.7%) out of which 609 (14.3%) were HR-HPV+ by the screening test including 114HPV 16 (18.7%), 41HPV 18 (6.7%), 454HR-HPVnon-16/18 (75.4%). A sample of 260 out of the 454HR-HPVnon-16/18 were genotyped by INNO-LiPA which revealed HPV52 (35%), 66 (22.6%), 51 (19.6%), 31 (15.7%), 39 (13%), 56 (10.4%), and 53, 35, 59, 33, 58, 82, 45, 68, 73 (<10% each). At month 12, a 2nd self-collection kit was sent to 274 of 609HR-HPV+ women who did not have a Pap-test previously performed on them. Of these 274 women, 130 provided a sample for HPV testing; one was uninterpretable, 56 were HPV negative, and 73 were HR-HPV+ (10HPV16+, 3HPV18+, 60HR-HPVnon-16/18+). Of the 345 women with cytological and/or histological follow-up 19 (5.5%) had ≥CIN2 lesions, (11 were HPV16+ and 8 were HR-HPVnon-16/18). CONCLUSION: This study illustrates the potential efficacy of self-sampling as a cancer screening strategy for socioeconomically deprived women who do not participate in regular Pap screening programs.

[HPV-Hr detection by home self sampling in women not compliant with pap test for cervical cancer screening. Results of a pilot programme in Bouches-du-Rhône]. / L'auto-prélèvement vaginal à domicile pour recherche de papilloma virus à haut risque. Campagne expérimentale du département des Bouches-du-Rhône.

The non-participation to cervical screening is the major determinant in the risk of mortality due to cervical cancer. In France, around 40% of women do not participate to regular screening. The cultural or economic barriers for performing screening by Pap test are numerous; one of the most frequent is the refusal of gynaecological examination. A persistent HPV(HR) infection is a necessary factor for developing cervical cancer. The HPV(HR) testing has a high sensibility to detect high grade cervical intra-epithelial neoplasia (CIN 2-3) and a satisfactory specificity after 30-35 years old. The principal objective of this study was to compare the participation rates in women 35-69 years old who did not perform a Pap test after a first individual invitation, either when an HPV(HR) auto-test was offered to be performed at home or a second invitation to Pap test was sent. We also evaluated the quality of the two tests, the positive results obtained by age groups and the following histological type of lesions diagnosed in the women with positive results. The study included 9,334 women, 35-69 years old, who did not realized a Pap-test during the 2 previous years and who did not respond at a first individual invitation. These non-responders were randomized into two groups: one group (n=4,934) received a second individual invitation and the other (n=4,400) an offer of receiving and performing an HPV auto-test at home. In women 35-69 years the participation to the second invitation to Pap test was significantly lower (7.2%) than the participation to auto-test (26.4%) with P<0.001. The quality of the two tests was satisfactory; the auto-test was not altered by the postage to laboratory (non interpretable rate=1.4% [CI at 95%=0.65%; 2.15%]. From the 311 Pap tests done, 5.5% (17) were classified "abnormal" (nine ASCUS, one high grade and seven low grades). The follow up of 13 women out of 17 confirmed the diagnosis for 1 case of CIN2 and 2 cases of CIN3, 4 women are lost of follow up after 6 months. From the 939 HPV(HR) tests done, 6.2% (58) were positive. Such positivity rate was not influenced by age. Out of the 58 positive HPV(HR) cases, 27 only were of the 16 genotype (46.5% [CI 95%=33.7%; 59.3%]). This law rate is a consequence of an inversion of the ratio HPV 16 versus other types in women 60 years old and over. In this group, the follow-up of 36 women diagnosed five cases of CIN1, one of CIN2 and four of CIN3; 22 patients are lost of follow up at 6 months. Globally, in the studied population, an individual recall for pap test allowed to diagnose and treat 3 high grade lesions (7‰) and the dispatching of an auto test allowed the diagnosis and treatment of five high grade lesions (1,4‰), this difference is significant (P=0.02; OR=0.25 [0.05; 0.97]). The HPV(HR) auto-test seems to be better accepted than the Pap test in the 35-69 years old women previously non-responders to individual invitation, and the quality of the test is satisfactory. Such a test can be proposed to the 35-69 years old non-participant to Pap test to increase the coverage for cervical screening, if the rates of diagnostic examinations performed in case of an HPV(HR) positive is sufficiently high.

Testing for human papillomavirus and measurement of viral load of HPV 16 and 18 in self-collected vaginal swabs of women who do not undergo cervical cytological screening in Southern France.

Self-sampling using vaginal swabs could be a valuable alternative to screen for cervical cancer for women who do not attend regular cytological screening. The aim of this study was to determine the prevalence of high and low-risk HPV types and of HPV type 16 and 18 DNA load in self-collected vaginal swabs from 35- to 69-year-old Southern French women of low socioeconomic level or migrant populations who do not attend regular cervical screening. A good concordance (93.1%) was found between cervical brush and vaginal swabs in 29 samples. Self-collected vaginal swabs were examined from 120 women. HPV infection was found in 28 women (23.3%; median age 48 years), 17 (14.1%) of whom harbored high-risk HPV types. HPV type 16 was the high risk type found most frequently, followed by types 53, 31, 18, 58, and 66. The low-risk type detected most frequently was HPV type 6, followed by types 61, 70, and 81. The mean HPV 16 and 18 load was 6.3 log(10) copies/10(6) cells and 2.4 log(10) copies/10(6) cells, respectively. These results suggest that vaginal self-swabs can be a reliable tool for cervical cancer screening in non-attending and inadequately screened elderly women.

[Organized cervical cancer screening for underpriviledged women]. / Le dépistage organisé des cancers du col utérin pour les femmes en situation médicosociale défavorisée.

Individual cervical screening with pap-smears is the major cause of the decrease in incidence and mortality of cervical cancer in France since more than 30 years. But, for the last ten years, the decrease in mortality is limited due to the persistence of poor prognostic cases and the insufficiency of treatment efficacy in such patients. These cases are mostly observed in women who did not participate to regular screening. They are generally from low socioeconomic levels or migrant populations, or both. Such an observation leads us to organize 3 successive pilot campaigns (2001, 2003, 2005) in the Northern part of Marseille city where the rate of such poor population is high (37 to 45%). The women without a pap-smear indexed in the National Insurance Register for the last 3-2 years were invited by individual mailing to perform, free of charge, a pap-smear. The evaluation of each campaign helps us to improve the next one. The major changes from the 1st one to the 3rd one were to increase the number of free screening services, to send a second invitation to the non responders, and to organize local meetings with social workers and nurses to explain to the women the importance of performing regular screening tests. The final results after the 3 campaigns showed : out of the eligible women the participation rates are dramatically low evolving from 1,56 % to 2,48% and 6,87% of pap-smears done along the 3 campaigns ; the selection of women "without pap-smear" from the national Insurance register was not good, a great number of missing data was identified, explaining partly the extremely low rate of participation ; the factors increasing a little the participation are the second mailing of invitation (39 % of pap-smears realised) ; the total gratuitous of the screening (both sampling and reading) ; the oral information delivered locally by social workers and the proximity of the places to perform the test ; the quality of the pap-smears collected by gynecologists was good but insufficient for other health professionals, requiring a specific training for cervical cell collection. The organization of such pilot projects need to be followed to find better solutions to increase the participation to cervical screening of such populations who are at high risk of poor prognosis cervical cancers.

Conservative treatment of cervical intraepithelial neoplasia using a cold-knife section technique.

OBJECTIVE: The purpose of this study was to evaluate a conservative cold-knife section technique for treatment of cervical intraepithelial neoplasia (CIN). This procedure can be adapted to patient age, preservation of childbearing potential and extent of dysplasia. DESIGN: Prospective study. SETTING: Gynecological Oncology Department in French Public Hospital. POPULATION: A total of 460 women treated for CIN between 1985 and 1999 were included. METHODS: A conservative cold-knife cervical section followed by blanket suture reconstruction was used in all cases. MAIN OUTCOME MEASURES: Immediate operative results, recurrence and reproductive function were assessed. RESULTS: The mean length of the cervical specimen was 11.4 mm (range, 4-22 mm). Mean specimen thickness was strongly correlated with age: 10.6 +/- 4.1 mm in women <40 years versus 12.1 in women >40 years; p < 0.001. Complete excision was achieved in 395 cases (85.8%). Post-operative bleeding was observed in 5 cases (1.1%). The mean duration of follow-up was 62 months (range, 12.3-156.5 months). Recurrences developed in 26 patients (6.6%) including CIN 1 in 9 cases, CIN 2 in 9 and CIN 3 in 8. No patient developed carcinoma. The actuarial risk of recurrence was 2.4% (+/- S.D., 0.9) at 24 months and 7.8% (+/-S.D., 1.9) at 60 months. A total of 52 pregnancies were observed in 39 patients. No case of de novo infertility was reported post-operatively. Amenorrhea was noted in 1 patient (0.1%) and dysmenorrhea in 1 patient (0.1%). CONCLUSIONS: This conservative cold-knife section technique is effective for treatment of CIN with low morbidity and little adverse effect on childbearing potential. Exposure of the squamocolumnar junction (SCJ) greatly facilitates follow-up.

[Accuracy of intraoperative frozen section diagnosis in non palpable breast lesions: a series of 791 cases]. / Efficacité de l'examen peropératoire des lésions infracliniques mammaires: études sur une série de 791 cas.

The aim of this study is to estimate the accuracy and reliability of intraoperative frozen section of nonpalpable breast lesions. In fact, frozen section of palpable breast lesions has proven to be valid, but its use in breast infraclinic lesions has been discussed recently, with the publication of European recommendations. Diagnosis on frozen section was routinely performed in a serie of 791 patients with nonpalpable mammographically detected abnormalities breast lesions from January 1990 through July 2000. The initial frozen section diagnoses with known mammographic pattern were compared with the diagnoses obtained on permanent paraffin sections to estimate the accuracy of frozen sections. Frozen section diagnosis was delayed until final diagnosis assessed on permanent paraffin sections in only 8 cases (1%). Frozen section diagnoses were accurate in 744 of 783 cases (95%). The diagnosis was modified on the basis of permanent sections in 39 cases; consisting of 39 false negative. No false positive diagnosis was noted. Sensitivity and specificity of frozen section diagnoses were 87,69 and 100, respectively. When the comparison between frozen and permanent section was analyzed according to the mammographic pattern, the sensitivity among patients with microcalcifications was lower (75,23) than among patients with opacities (93,86). When frozen section and permanent section diagnoses were related according to the mammographic size ( 10 mm) the sensitivity among patients with opacities measuring less than 10 mm was lower (91,75) than among patients with opacities larger than 10 mm (95,65) and the sensitivity among patients with microcalcifications larger than 10 mm was greater (77,14) than among patients with microcalcifications size less than 10 mm (74,28). This results are similar to those obtained on palpable breast lesions, and show that frozen section is a feasible and reliable procedure in nonpalpable breast lesions, particularly more relevant in mammographic opacities than in microcalcifications, whatever the lesion size.

[Antecedents of cytological screening among patients treated for invasive cervical neoplasm]. / Antécédents de dépistage cytologique chez les patientes traitées pour cancer infiltrant du col de l'utérus.

OBJECTIVE: The aim of this study is to evaluate if the seriousness of invasive neoplasms of the uterin cervix actually observed is related to the apparition of rapid onset cases. POPULATION: 219 invasive cancers of the cervix treated from 1988 to 1999 in a gynecological oncologic department. METHODS: prognostic factors of cancers have been studied and compared to those of cases treated between 1975 and 1980 in the same department. The existence of cytological screenings has been searched and results have been analysed. RESULTS: Cervical cancers treated during the last 12 years have more serious prognostic factors than those treated during the former period. This evolution is shown by a progression of advanced stages of + 10.2%, an increase of lymph node invasion in proximal stages of + 13,4% and the doubling of number of adenocarcinomas. Though no change of the natural history of cancers has been proved. Only 42% of patients had profited of a cervical screening and cancers diagnosed at "stage I" are statistically more numerous in this group. Improvement should be brought up in the quality of samplings and of the care of abnormal results of cytological screening.