Cervical Cancer Screening Modalities Research Articles

Detection of high-risk human papillomavirus using menstrual blood in women with high-grade squamous intraepithelial lesions or high-risk human papillomavirus infections: A pilot study.

Few studies have reported that human papillomavirus (HPV) tests using menstrual blood (MB) may be a convenient and effective screening modality for cervical cancer. Therefore, we aimed to investigate the efficacy of detecting high-risk (HR)-HPV from MB in women with high-grade squamous intraepithelial lesions or HR-HPV infections dependent on menstrual days. In this prospective exploratory pilot study, a clinical trial was conducted in 19 women. On enrollment into the study, gynecologists collected cervical cells. On the first and second day of menstruation, MB was self-collected by patients using a sanitary pad with a filter. The distribution of HPVs from MB and the accuracy of menstrual HR-HPV tests were evaluated using HPV genotyping. The agreement rate of detecting HR-HPVs using cervical and MB samples was also investigated. The sensitivity, specificity, positive and negative predictive values of the MB HR-HPV test for detecting cervical intraepithelial neoplasia (CIN) 3 or worse were 87.5%, 45.5%, 53.8%, and 83.3%, respectively, during both menstrual cycle day (MCD) 1 and 2 and MCD 1 only; and 62.5%, 27.3%, 38.5%, and 50.0%, respectively, during MCD 2 only. For CIN 3 or worse, the agreement rate between positive cervical and MB HR-HPV test results was 87.5% during MCD 1 and 62.5% during MCD 2. We demonstrated the possibility of using the MB HPV test as a screening modality for cervical cancer.

Barriers and Facilitators to Cervical Cancer Screening Among Women in Rural Ontario, Canada: The Role of Self-Collected HPV Testing.

The addition of human papillomavirus (HPV) testing to primary cervical cancer screening provides an opportunity to employ less invasive cervical cancer screening modalities. The objective of this study was to explore the initial reaction and perception to HPV self-collected testing, in the context of current barriers and facilitators to cervical cancer screening, among women in an underscreened community in rural Ontario. Age-stratified focus groups were conducted with women 18-70 years of age in rural Ontario to discuss cervical cancer screening. Women were recruited using purposive sampling of underscreened women and women in the general community. Qualitative thematic analysis of focus group transcripts identified the barriers, facilitators, and role of HPV self-collected testing for cervical cancer screening. Four focus groups were conducted with a total of 25 women. Overall, women were very positive toward self-collected HPV testing. HPV self-collected testing was felt to address many of the logistical (eg, inconvenient clinic hours, lack of time) and procedural barriers (embarrassment, lack of social distance in a small town) to current screening practices. However, self-collected HPV testing does not address barriers related to cervical cancer knowledge (eg, fear of cancer). Women identified issues related to test reliability, confidence in the ability to self-collect, and education around testing that would need to be addressed prior to implementation. Generational differences were noted in the acceptability of self-collected HPV testing between older and younger women. HPV self-collected testing was perceived as a facilitator for screening, and it was well accepted in this rural community.

Cervical Cancer Screening Practices among Rural Indian Women

Background: Cervical cancer is a major health problem in India. The aim of this paper was to find the cervical cancer screening practices among rural Indian women. Method: This cross- sectional study was carried out in 3 villages of Udupi, India among 407 married women in the aged 221- 65 years. Data was collected using interviewer administered questionnaires. Results: The mean age of the women who participated in the study was 43.17 ± 13.43 with the age range from 21- 65 years. It was determined that more than half of the women (68.3 %) were Hindu. 37.1% had completed primary school education. Majority of the participants (40%) had monthly income less than 5000 rupees. 98% were living with their spouse. Most of them (77.3 %) were married within 18-25 years. Majority of the women belonged to joint family (53.6 %). It was found that none of the 407 participants had ever had a Pap test in their lifetime and only 6.1 % were aware of the Pap test as a screening modality for cervical cancer. Lack of awareness was cited by more than half of the women as the reason for not undergoing cervical cancer screening. Conclusion: From this it can be inferred that lack of awareness is a major barrier for not undergoing screening. An organized health education programme focusing on women with the participation of health care workers is sorely needed.

Can visual inspection with acetic acid be used as an alternative to Pap smear in screening cervical cancer?

Abstract Objective To evaluate the value of visual inspection with acetic acid (VIA) in screening cervical cancer in comparison to Pap smear. Material and methods 200 women attending the obstetric and gynecology Department in Zagazig University hospital from December 2011 to November 2012 were included. They were screened using Pap smear and VIA. Colposcopy was done for all women. Positive cases on any screening test were subjected to cervical biopsy. Results Acetic acid (VIA) was positive in 24/200 (12%) patients and Pap smear was abnormal in 8 (4%). There were 5 LSIL, 2 HSIL and one with cells suspicious of malignancy. Colposcopy was recorded abnormal in 35 cases (17.5) .18 cases (51.4%) had a Reid score of 0–2 and considered negative .17 cases (48.6%) had a positive colposcopy (Reid 3–8). Cervical biopsy was done on all 35 cases. 44% biopsies were positive and 56% were negative .15 positive biopsies incorporated 11 mild dysplasia, 2 moderate dysplasia, 1 sever dysplasia and one carcinoma in situ. The Pap smear had a sensitivity of 50.1%, specificity of 93.1%, and positive predictive value of 89.3% and negative predictive value of 65.6%. VIA had a sensitivity of 90%, specificity of 37%, and positive predictive value of 52% and negative predictive value of 81%. Conclusion VIA a good screening, simple test, has low cost and high sensitivity in comparison to Pap smear. So, it can be used as alternative screening modality for cervical cancer in low resource locations.

Cost-effectiveness analysis on the once-in-a-lifetime cervical cancer screening program for women living in rural and urban areas of China

To estimate the cost-effectiveness of once-in-a-lifetime cervical cancer screening program and to predict the optimal modality for its operation on women living in rural and urban areas of China, based on Markov modeling and simulation. Three modalities including visual inspection with acetic acid plus Lugol's iodine (VIA/VILI), conventional Pap Smear (Pap Smear), and simple HPV DNA testing (careHPV) were hypothesized for the rural cohort, whereas other five modalities including Pap Smear, liquid-based cytology (LBC), simple HPV DNA testing (careHPV), Hybrid Capture 2 HPV DNA testing (HC2), and LBC plus HC2 (LBC + HC2) were tested for the urban cohort. A Markov model was constructed based on the factors as natural history, screening, diagnosis and treatment on cervical cancer using data related to the epidemics and the costs from rural and urban areas of the country. Long-term effectiveness and cost-effectiveness were predicted through simulation of the model. Compared to the non-screening scenario, the amount of life years saved were 277.97 - 2727.53 and 134.02 - 1446.84 years per 100 000 women, respectively, for different cohorts in rural and urban areas. The cost-effectiveness ratios were 1520.99 - 2453.74 and 3847.35 - 44 570.35 RMB per life year saved, respectively, for different cohorts in rural and urban areas. The incremental cost-effective ratio for careHPV starting from 40 years old (careHPV@40) and careHPV from 30 years old (careHPV@30) dominated other strategies for the rural cohort, while careHPV@40, careHPV@30, HC2 from 30 years old (HC2@30), and LBC + HC2 from 30 years old (LBC + HC2@30) were dominant for the urban cohort. All eight once-in-a-lifetime cervical cancer screening modalities were cost-effective based on our model. In particular, careHPV screening starting from 40 years old seemed to be the most cost-effective one for women living in both rural and urban areas.

Estimating the long-term effects of HPV vaccination in Germany

In Germany, vaccination against the most oncogenic HPV types 16/18 is recommended by the Standing Committee on Vaccination (STIKO) for 12–17 year old girls since March 2007. We developed a dynamic mathematical model for the natural history and transmission of HPV infections to estimate the impact of vaccination on incidence and mortality of cervical cancer and its pre-stages, and on anogenital warts. We focused on an extensive model calibration to epidemiologic data for all stages of the natural history model as well as on a detailed implementation of cervical cancer screening modalities in Germany. Our model predicts first a substantial reduction of cervical cancer incidence and mortality over the next 30 years, which is mainly attributable to an increase in screening participation in the 1990s and not to HPV vaccination, followed by a further reduction attributable to vaccination. Over the next 100 years, HPV vaccination will prevent approximately 37% of cervical cancer cases even if vaccination coverage is only 50% (as currently observed in Germany). Consideration of cross-protection results in a further reduction of approximately 7% of all cervical cancer cases for the bivalent and about 5% for the quadrivalent vaccine in our model. Vaccination of boys was only reasonable if moderate to high vaccination coverage in girls was not achieved. Strategies should be implemented in Germany to increase HPV vaccination coverage among girls thereby making better use of the demonstrated benefits of the vaccine.

Clinical Utility of HPV Testing

Testing for human papilloma virus (HPV) has been shown to be more sensitive than cervical cytology in detecting both high-grade and low-grade dysplasia. When screening for cervical cancer, unfortunately, the HPV test lacks specificity and has limited its usefulness as a primary screening modality for cervical cancer. In this chapter, we will review HPV and its role in cervical cancer, the utilization of HPV testing in current practice, and the possible future utilization of HPV and its role in screening.

See-and-Treat Approaches to Cervical Cancer Prevention for HIV-Infected Women

Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.

Diagnostic value of acetic acid comparing with conventional Pap smear in the detection of colposcopic biopsy-proved CIN

To assess the role of visual inspection with acetic acid as an alternative to Pap smear and in screening program for cervical cancer in low resource settings. A total of 225 women in the reproductive age group attending the Department of Gynecology were enrolled in the study. A Papanicolaou smear and visual inspection of the cervix with acetic acid was done. All patients who tested positive on screening then underwent a colposcopy-guided biopsy. The Pap smear of a low-grade squamous intraepithelial lesion (LSIL) and above was taken as abnormal. The statistical test used was the chi-square test and results were computed using Statistical Package for the Social Sciences (SPSS) version 12.0. Out of 225 patients, acetic acid (VIA) was positive in 27 (12%) patients and the Pap smear was abnormal in 26 (11.7%). There were 15 LSIL, 6 high grade squamous intraepithelial lesions (HSIL) and 5 were squamous cell carcinoma. On biopsy, there were 15 mild dysplasia, 2 moderate dysplasia, 4 severe dysplasia, and 3 squamous cancers. The Pap smear had a sensitivity of 83%, specificity of 98%, and positive predictive value of 80% and negative predictive value of 97.9%. VIA had a sensitivity of 70.8%, specificity of 95%, and positive predictive value of 62.9% and negative predictive value of 96.5%. Since diagnostic values of VIA is comparable to Pap smear, and it performs well in detecting a high grade lesion, we conclude that VIA can be used as a screening modality for cervical cancer in low resource settings.

Barriers to Acceptance of Self-sampling for Human Papillomavirus across Ethnolinguistic Groups of Women

Immigrant and low socio-economic (SES) women in North America underutilize Papanicolaou screening. Vaginal swab self-sampling for oncogenic human papillomavirus (HPV) has the potential to increase cervical cancer screening participation. The purpose of this qualitative study was to understand the perceptions of lower SES and immigrant women regarding self-sampling for HPV. Eleven focus-group interviews were conducted: one with Canadian-born English-speaking lower SES women, and two groups each with Arabic, Cantonese, Dari (Afghani), Somali and Spanish (Latino)-speaking women (one group conducted in English, the other in the native language) recently immigrated to Canada. Five to nine women aged 35 to 65 years and married with children participated in each group. Themes included 1) who might use self-sampling and why; 2) aversion to self-sampling and reasons to prefer physician; 3) ways to improve the appeal of self-sampling. Women generally perceived benefits of self-sampling and a small number felt they might use the method, but all groups had some reservations. Reasons included: uncertainty over performing the sampling correctly; fear of hurting themselves; concern about obtaining appropriate material; and concerns about test accuracy. Women preferred testing by a health care professional because they were accustomed to pelvic examinations, it was more convenient, or they trusted the results. Perceptions of self-sampling for HPV were similar across cultures and pertained to issues of confidence in self-sampling and need for physician involvement in care. These findings can inform programs and studies planning to employ self-sampling as a screening modality for cervical cancer.

Cervical cancer in resource-limited settings: preventable but not yet prevented

Women in developing countries suffer a high burden of cervical cancer, which remains a leading cause of cancer deaths among women. Recent developments, however, suggest that there is hope for cervical cancer control even in resource-limited settings. Owing to the scarcity of healthcare resources, it is imperative that an appropriate cost-effective screening strategy be adopted to obtain optimal results. This article reviews the performance characteristics, merits and limitations of the available primary and secondary screening modalities for cervical cancer with a particular focus on the role of alternative strategies in developing countries. An algorithm for an optimal screening strategy in resource-limited settings is conceptualized. Future research issues aimed at refining the existing tools and developing low-cost screening technologies are also addressed.

Test characteristics of various screening modalities for cervical cancer: a feasibility study to develop an alternative strategy for resource‐limited settings

To determine test characteristics - sensitivity, specificity, positive and negative predictive values - of different screening modalities to detect cervical precancerous and cancerous lesions in order to devise an effective alternative strategy for cervical cancer screening in resource-poor settings. A total of 472 women presenting with nonspecific gynecologic symptoms were screened by cytology, visual inspection with acetic acid application (VIA), VIA with magnification (VIAM) and human papillomavirus (HPV)-DNA testing. Colposcopic examination was performed in all and on-site biopsy was taken if any grade I and above lesion was detected on colposcopy (230). On histopathological examination, 105 showed cervical intraepithelial neoplasia II and above lesions. Sensitivity, specificity and predictive values for each test were calculated taking colposcopy and or directed biopsy as the gold standard. Comparisons were made with cytology in order to assess the feasibility of alternative strategies in resource-poor settings. VIA was less sensitive (86.7% versus 91.4%) but more specific (90.7% versus 86.6%) than cytology at low grade squamous intraepithelial lesion (LSIL) threshold but the difference was not statistically significant (P > 0.01). HPV testing improved the sensitivity over cytology (97.1% versus 91.4%) but there was a nonsignificant loss of specificity (84.2% versus 86.6%). Results of VIAM were more or less similar to VIA. VIA can be used as a mass screening tool for cervical cancer in resource-poor settings.

Diagnostic Value of VIA Comparing with Conventional Pap Smear in the Detection of Colposcopic Biopsy Proved CIN

Aim: A study to assess the role of visual inspection with acetic acid VIA as an alternative to Pap smear in screening program for cervical cancer in low resource settings. Method: Two hundred and twenty five women in reproductive age group attending the Gynecology department at K.S Hegde Charitable Hospital were enrolled in the study. A Papanicolaou smear and visual inspection of the cervix with acetic acid was done. All women then underwent colposcopy using the video colposcope. All patients who tested positive on screening then underwent colposcopy guided biopsy. Pap smear of Low grade squamous intraepithelial lesion (LSIL) and above was taken as abnormal. The statistical test used was chi square test and results were computed using Statistical Package for the Social Sciences (SPSS) version 12.0. Results: Out of 225 patients, VIA was positive in 27(12%) patients and Pap smear was abnormal in 26(11.7%). There were 15 LSIL, 6 high Grade Squamous intraepithelial lesions (HSIL) and 5 were squamous cell carcinoma. On biopsy, there were 15 mild dysplasia, 2 moderate dysplasia, 4 severe dysplasia and 3 squamous cancers. Pap smear had a sensitivity of 83%, specificity of 98%, and positive predictive value of 80 % and negative predictive value of 97.9%. VIA had a sensitivity of 70.8%, specificity of 95%, and positive predictive value of 62.9 % and negative predictive value of 96.5%. Conclusion: Since diagnostic values of VIA is comparable to Pap smear, and it performs well in detecting high grade lesion we conclude that VIA can be used as a screening modality for cervical cancer in low resource settings. Keywords: Cervical cancer in low resource settings, Pap smear- colposcopy, visual inspection with acetic acid DOI: http://dx.doi.org/10.3126/njog.v6i1.5245 NJOG 2011; 6(1): 7-12

Diagnostic value of VIA comparing with conventional pap smear in the detection of colposcopic biopsy proved CIN

Introduction: Cervical cancer, the leading malignancy among Indian women is preventable and curable if detected at an early stage using proper screening tools. We conducted a study to assess the role of visual inspection with acetic acid as an alternative to pap smear and in screening program for cervical cancer in low resource settings. Methods: Two hundred and twenty five women in reproductive age group attending the Gynecology department at K.S Hegde Charitable Hospital were enrolled in the study. A Papanicolaou smear and visual inspection of the cervix with acetic acid was done. All women then underwent colposcopy using the videocolposcope. All patients who tested positive on screening then underwent colposcopy guided biopsy. Pap smear of low grade squamous intraepithelial lesion (LSIL) and above was taken as abnormal. The statistical test used was chi square test and results were computed using SPSS version 12.0. Results: Out of 225 patients, VIA was positive in 27(12%) patients and pap smear was abnormal in 26(11.7%). There were 15 LSIL, 6 high grade squamous intraepithelial lesion (HSIL) and 5 were squamous cell carcinoma. On biopsy, there were 15 mild dysplasia, 2 moderate dysplasia, 4 severe dysplasia and 3 squamous cancers. Pap smear had a sensitivity of 83%, specificity of 98%, positive predictive value of 80 % and negative predictive value of 97.9%. VIA had a sensitivity of 70.8%, specificity of 95%, and positive predictive value of 62.9 % and negative predictive value of 96.5%. Conclusion : Since diagnostic values of VIA is comparable to pap smear, and it performs well in detecting high grade lesion we conclude that VIA can be used as a screening modality for cervical cancer in low resource settings. Keywords: visual inspection with acetic acid; pap smear- colposcopy; cervical cancer; low resource settings DOI: http://dx.doi.org/10.3126/hren.v9i3.5579 HR 2011; 9(3): 134-139