Reduction In Cervical Cancer Mortality Research Articles

Temporal trends, spatial and spatiotemporal clusters of cervical cancer mortality in Brazil from 2000 to 2021

Cervical cancer, despite being preventable through primary and secondary prevention strategies, remains one of the leading causes of morbidity and mortality among women in Brazil. This study aimed to analyze the temporal, spatial, and space-time patterns of cervical cancer mortality in Brazil. An ecological study was conducted using temporal, spatial, and space-time analysis techniques, using death certificates with cervical cancer as the underlying cause or associated condition among females in Brazil from 2000 to 2021. Death certificate and population data were provided by the Department of Health Informatics of the Unified Health System (DATASUS) and the Brazilian Institute of Geography and Statistics (IBGE), respectively. A total of 123,306 deaths associated with cervical cancer among women were registered during the study period. A rising trend in mortality was detected since 2014 onwards, after 14 years of decline. Particularly, an increase in mortality was observed among the younger age groups, and in the North and Northeast regions regardless of age. Heterogeneity in the spatial distribution of cervical cancer mortality was observed, with high mortality clusters around the country, but mostly concentrated in the North and Northeast regions. These findings suggest a need and an opportunity to develop efficient and effective health policies targeting those regions and groups of women at higher risk which in turn will allow for fast and significant reductions in cervical cancer mortality in Brazil.

Policy analysis of cervical cancer prevention in Iran based on the policy triangle model

BACKGROUND: Widespread use of screening in high-income countries has led to a significant reduction in cervical cancer mortality. Most low- and middle-income countries still have poorly organized screening programs. This study aimed at policy analysis of prevention and early detection of cervical cancer in Iran, a middle-income country. MATERIALS AND METHOD: This qualitative retrospective study, extended by the health policy triangle model, was conducted from July 2020 to September 2021. A sample of this study consisted of 43 participants, including 16 key policy experts; nine 11 senior health system managers, 13 executives, and 3 clients selected purposefully. Data were collected through semi-structured interviews using the interview guide and analyzed using a framework analysis method based on the policy triangle model in MAXQDA2020. RESULTS: Nine themes, 15 subthemes, and 36 codes were extracted based on the 4 dimensions of the model; stakeholder analysis challenges, including conflict of interest and decision-making challenges. Moreover, the most important policy process challenges indicated the weakness of monitoring and evaluation systems and weakness of using scientific principles in policy making. Weakness of organizational and intersectoral structure and weakness of executive management were obtained among the challenges in the context analysis. Finally, the most important challenges related to content analysis are weaknesses in applying scientific principles in policy making, including weaknesses in standard operating procedures, and low use of HTA capacity in developed guidelines. CONCLUSION: A wide range of economic, social, and cultural problems can affect cervical cancer prevention policies. Several strategies are suggested to overcome these challenges, including allocating separate funds to cancer prevention programs, using structures to sustain prevention programs, designing, and using them to improve public awareness.

Cervical cancer mortality among young women in Latin America and the Caribbean: trend analysis from 1997 to 2030

BackgroundCervical cancer continues to show a high burden among young women worldwide, particularly in low- and middle-income countries. Limited data is available describing cervical cancer mortality among young women in Latin America and the Caribbean (LAC). The purpose of this study was to examine the mortality trends of cervical cancer among young women in LAC and predict mortality rates to 2030.MethodsDeaths from cervical cancer were obtained from the World Health Organization mortality database. Age-standardized mortality rates per 100,000 women-years were estimated in women aged 20–44 years using the world standard population for 16 countries (and territories) in LAC from 1997 to 2017. We estimated the average mortality rates for the last 4 years (2014–2017). Joinpoint regression models were used to identify significant changes in mortality trends. Nordpred method was used for the prediction of the mortality rates to 2030.ResultsBetween 2014 and 2017, Paraguay and Venezuela had the highest mortality rates of cervical cancer, whereas Puerto Rico had the lowest rates. Overall, most of the LAC countries showed downward trends of cervical cancer mortality over the entire period. Significant decreases were observed in Chile (Average annual percent change [AAPC]: − 2.4%), Colombia (AAPC: − 2.0%), Cuba (AAPC: − 3.6%), El Salvador (AAPC: − 3.1%), Mexico (AAPC: − 3.9%), Nicaragua (AAPC: − 1.7%), Panama (AAPC: − 1.7%), and Peru (AAPC: − 2.2%). In contrast, Brazil (AAPC: + 0.8%) and Paraguay (AAPC: + 3.7%) showed significant upward trends. By 2030, mortality rates are not predicted to further decrease in some LAC countries, including Argentina, Paraguay, and Venezuela.ConclusionsMortality trends of cervical cancer among young women have large variability in LAC countries. Cervical cancer screening programs have a high priority for the region. Primary and secondary prevention in the community are necessary to accelerate a reduction of cervical cancer mortality by 2030.

Value of PAP’s Smear with Regard to DNA Testing for Identification of Cervical Precancerous Lesions in VIA Positive Cases

Background: Carcinoma cervix is one of the cause of female death in developing country like Bangladesh. Prevention can be done by several screening procedure like VIA, Pap's smear, HPV DNA testing, Colposcopy and colposcopy directed biopsy. We can markedly reduce the mortality and morbidity by these procedures and can be detected carcinoma in precancerous and very early carcinoma stage. This study was conducted to compare HPV DNA testing and pap’s smear for identification of cervical precancerous lesions in VIA positive cases.
 Materials and methods: It was an analytical type of cross sectional study. Data were obtained in outpatient Department of Gynecology and Obstetrics, Chattogram Medical College Hospital, Chattogram from July 2014 to December 2014. Total 90 subjects were included in the study consecutively after considering inclusion and exclusion criteria and taking written informed consent. Data analysis was done by SPSS (Version 17).
 Results: Histopathology findings of biopsy materials of colposcopy positive cases where 8(28.6%) were chronic cervicitis, 10(35.7%) were CIN I, 7(25.0%) were CIN II, 3(10.7%) were CIN III. Total 20(71.4%) cases were found positive or precancerous. Regarding validity analysis of different tests that were performed for cervical precancerous conditions taking histopathology results as a gold standard, sensitivity of Pap’s smear was found lower (75.0%) than the HPV DNA whereas specificity of Pap’s Smear was higher (87.5%) then the specificity of HPV DNA (75.0%).
 Conclusion: HPV DNA testing was both more sensitive and specific near to Pap cytology. So the use of a less invasive and more user friendly primary screening strategy like HPV-DNA testing may be required to achieve the coverage necessary for effective reduction in cervical cancer mortality.
 Chatt Maa Shi Hosp Med Coll J; Vol.18 (2); July 2019; Page 27-32

Women's attitudes and understanding of cervical cancer and the new National Cervical Screening Program.

The new National Cervical Screening Program (NCSP) has recently been implemented. Little research is available on women's attitudes towards the program. This study aims to quantitatively assess Australian women's understanding and attitudes towards the new guidelines and their barriers to screening. Authors designed a cross-sectional survey which was piloted and distributed as a waiting room survey to eligible women who attended a private general practice in North Queensland. Of the respondents, 53.8% had accurate knowledge of the new NCSP. Most participants (75.8%) believed they were not provided sufficient information about the NCSP and 60.2% wished to receive this information from their general practitioner. The screening test itself remains an issue, with embarrassment and discomfort listed as the most common barriers to screening. Many women do not have accurate knowledge of the new NCSP. Further health promotion in this area is warranted, where the general practitioner may play a key role. SO WHAT?: While the new NCSP will lead to further reduction in cervical cancer mortality, it appears from the data that women did not fully understand cervical cancer and its screening. This suggests the need for further health education to women about updated screening guidelines.

National Policies to Prevent and Manage Cervical Cancer in East African Countries: A Policy Mapping Analysis.

Policy mapping is used to provide evidence on effective interventions and highlight the necessary refinements of health policies. The goal of this work is to carry out legal mapping to identify and assess health policies for the prevention and management of cervical cancer in East African countries. Cervical cancer, as a largely preventable disease, is the cause of most cancer deaths among women in East African countries. Legal documents were searched uniformly from government websites, national cancer institute sites, and international and national legal databases, then the data were analyzed using the Nvivo12 software package. The sample of 24 documents includes policies, plans, guidelines, acts, and strategies from 12 East African countries. The emerging themes were screening, prevention, diagnosis, treatment, challenges, and mitigation efforts. A few binding policies, a significant discrepancy to international standards in at least four countries, patchy screening registries, and a lack of prophylactic vaccination against human papillomavirus incorporation into national immunization schedules are the main findings. This paper underlies the role of law in health and the need for transparent legal and regulatory tools to achieve a further reduction in cervical cancer mortality in East African countries.

Dominican Provider Practices for Cervical Cancer Screening in Santo Domingo and Monte Plata Provinces.

Cervical cancer is the second leading cause of cancer death for women in the Dominican Republic. Pap smear screening in the Dominican Republic has not achieved adequate reduction in cervical cancer mortality. The purpose of this study was to examine Dominican provider practices for cervical cancer screening and the use of national or international screening guidelines. We surveyed 101 gynecology specialists, 50 non-specialists, and 51 obstetrics-gynecology residents in the Santo Domingo and Monte Plata provinces of the Dominican Republic regarding their cervical cancer screening practices and use of guidelines. Bivariate (chi-square) analyses were conducted to compare screening practices by demographic and practice characteristics. The majority of providers followed WHO guidelines (62.9%) and/or Dominican national norms (59.4%). The majority (87%) of providers use time since first sexual activity as the basis for screening initiation; 96% advise screening every 6-12months. The most commonly used screening test is the conventional Pap smear. Colposcopy was recommended most often for all abnormal Pap results. Dominican providers report they follow national and/or international cervical cancer screening guidelines. They do not follow age-based screening guidelines, nor have they adopted an extended interval for screening and continue to recommend screening at least annually. A culture of early and frequent screening has consequences in terms of cost, high demand for follow-up services, and reduced capacity to reach the populations at highest risk. Early screening also may challenge the acceptability of adopting alternative screening technologies such as HPV testing.

Estimating the epidemiological impact and cost-effectiveness profile of a nonavalent HPV vaccine in Spain

ABSTRACT Human papillomavirus (HPV) is one of the main causes of infection-related cancer. The bivalent vaccine (2vHPV) (16/18) and quadrivalent (6/11/16/18) HPV vaccine (4vHPV) have been included in the Spanish vaccination calendar since 2007. The new nonavalent HPV vaccine (9vHPV), approved in Europe in 2015, includes nine HPV types 6/11/16/18/31/33/45/52/58 and has been available in Spain since May 2017. Our study aims to estimate the epidemiological impact and the cost-effectiveness of a girls-only and a gender-neutral vaccination program with 9vHPV compared to the current vaccination program in Spain. A dynamic transmission model simulating the natural history of HPV infections was calibrated to the Spanish setting and applied to estimate costs and quality-adjusted life years (QALYs) associated with vaccination strategies using a payer perspective and a 100-year time horizon. A girls-only vaccination strategy at age 12 years with 9vHPV was found to be a cost-effective strategy compared with 4vHPV (incremental cost-effectiveness ratio (ICER) of €7,718 per QALY). Compared with girls-only vaccination with 4vHPV, gender-neutral vaccination with 9vHPV was associated with further reductions of up to 28.5% in the incidence of cervical intraepithelial neoplasia (CIN) 2/3 and 17.1% in the incidence of cervical cancer, as well as with a 14.0% reduction in cervical cancer mortality. Furthermore, a gender-neutral vaccination program with 9vHPV could potentially be cost-effective considering some parameters as head and neck protection or discount rates, leading to a reduction in the burden of HPV-related diseases in both sexes in the Spanish population.

Establishment of Structured Preventive Mobile Cancer Care in Nigeria: A Success Story

Background and context: Mass medical mission is a nonprofit, public health charity aimed at complementing the effort of government in improving the health indices of Nigerians. Its core initiative is the National Cancer Prevention Program (NCPP), a foremost effort toward national cancer control in Nigeria. In 2007, NCPP spearheaded community-based mass cervical cancer screening in Nigeria, initially known as National Cervical Cancer Prevention Program (NCCPP). This effort has contributed to a 15% reduction of cervical cancer mortality in Nigeria, from 9659 deaths to 8240 deaths, between 2008 and 2012 (GLOBOCAN data). The improvement in cervical cancer survivorship in Nigeria was proof positive that winning the fight against cancer was possible if the effort could be scaled up. Consequently, mass medical mission escalated its advocacy drive, which was tagged the Big War Against Cancer in Nigeria. Aim: The short-term goal was to raise funds toward the provision one Mobile Cancer Centres (MCC) for each state and a Comprehensive Cancer Centre for each of the six geopolitical zones in the long-term. Strategy/Tactics: Mass medical mission initiated the establishment of a fundraising platform known as the Committee Encouraging Corporate Philanthropy (CECP-Nigeria). A private sector led initiative to promote concerted and synergistic philanthropy for the common good through public-social-private partnership. The President of Nigeria is the grand patron while the Vice President, the National Patron. Returns: Through this effort, four of the pilot set of MCC (known as PinkCruise) are now in Nigeria, one of which was donated by the Lagos State Governor. The fixed centers from which the PinkCruise operate have also been set up in four selected cities representing the four old regions of Nigeria. These mobile units are unique as they are multifunctional with state-of-the-art facilities for screening, follow-up and treatment (including mammography, endoscopy, colonoscopy, colposcopy, cryotherapy, laboratory, vaccination and surgeries for precancer and early cancer). The PinkCruise have been deployed to carry out systematic mobile health outreaches, known as Mission PinkCruise, which also have an eye-care aspect known as Mission PinkVISSION. PinkVISSION is also an initiative of mass medical mission (mmm), aimed at achieving the goals of “Vision 2020: The Right to Sight”, by incorporating preventive eye care into cancer prevention and general health promotion. The acronym, VISSION, stands for Voluntary Integrated Sight Saving Initiative Of Nigeria. Both Mission PinkCruise and Mission PinkVISSION are free of charge to the hosts and the beneficiaries. What was learned: The synergy between PinkVISSION and PinkCruise results in improved uptake, impact and cost effectiveness of both the cancer campaign and the eye campaign.

The accuracy of the causes of death and the estimated trend: the case of cervix uteri

reduction in cervical cancer mortality is the ultimate goal of the screening. Quality of death certificate reports has been improved over time, but they are still inaccurate, making it difficult to assess time trends in mortality. to evaluate the accuracy of the topographic coding of causes of death and to estimate the mortality time trend for cervical cancer through the method of incidence-based mortality (IBM) using cancer registry (CR) data. from the mortality registry (MR), we extracted data on deaths for cervix uteri cancer, corpus uteri cancer, and uterus cancer not otherwise specified (NOS) referred to residents in Reggio Emilia (Emilia-Romagna Region, Northern Italy) from 1997 to 2013. Deaths were checked with the CR to verify the topographical site of the primary tumour. Furthermore, by using CR data, we constructed a cohort of incident cervical cancer cases diagnosed between 1997 and 2009 with a 5-year follow-up. We calculated cause-specific IBM (excluding ovary) and IBM for all cause, crude and standardized, and annual percentage change (APC). out of 369 deaths for uterine cancer, 269 were reported in the RT: 32 for cervix uteri cancer, 76 for corpus uteri cancer, 161 for uterus cancer NOS. 28 of the 32 persons who died for cervical cancer were incidents for cervix uteri cancer. 63 of the 76 who died for corpus uteri cancer were incidents for corpus uteri cancer. Of the 161 who died of uterus cancer NOS, 80 were incidents for corpus uteri cancer, 45 for cervix uteri cancer, 28 for uterus cancer NOS, 5 for vagina cancer, and 3 for cancer of other non-specified organs. Applying these proportions of misclassification, we can estimate that the real number of cervical cancer deaths is 2.4 folds the number of cases reported in the MR as cervical cancer. IBM for all causes decreased significantly over the years (APC: -9.5; 95%CI -17.1;-1.1); cause-specific IBM decreases, but not significantly (APC: -5.1; 95%IC -16.1;+7.3). There is no improvement in survival (r2=0.02; p=0.6), while the incidence shows a decrease (APC: -6.6;95%CI -10.0;-3.0). mortality for cervical cancer is still underestimated by deaths certificates: for each reported case, there are other 1.4 cases that are reported with other less specific causes.

Utilization patterns of cervical cancer screening in Italy.

The aim of this study is to identify the use of cervical cancer screening and sociodemographic determinants associated with proper screening, overscreening, and underscreening in the Italian target population. Cross-sectional data from the national last available survey 'Health and use of health care in Italy,' conducted between December 2004 and September 2005, were analyzed. Multiple logistic regression was used to evaluate the risk factors associated independently with Pap test utilization. Our final sample included 36,161 women aged 25-64 years. Among women who reported having a Pap smear at least once, 20,920 (81.6%) repeated the Pap smear after the first one: 15,454 (74.3%) more than once every 3 years ('OVER' screening) and 2599 (12.4%) less than once every 3 years ('UNDER' screening). Among the independent risk factors associated with 'OVER' screening were higher social class [odds ratio (OR)=1.26, 95% confidence interval (CI) 1.15-1.39], being a former smoker (OR=1.16, 95% CI 1.05-1.28), and having had two or more pregnancies in the last 5 years (OR=1.43, 95% CI 1.20-1.70), whereas 'UNDER' screening was associated with the age group of 55-64 years (OR=2.11, 95% CI 1.76-2.53) and being divorced (OR=1.32, 95% CI 1.02-1.71). Improving Pap test compliance according to the proper timing is important for future reduction in cervical cancer mortality.

Effect of VIA Screening by Primary Health Workers: Randomized Controlled Study in Mumbai, India

Cervical cancer is the leading cause of cancer mortality among women in India. Because Pap smear screening is not feasible in India, we need to develop effective alternatives. A cluster-randomized controlled study was initiated in 1998 in Mumbai, India, to investigate the efficacy of visual inspection with acetic acid (VIA) performed by primary health workers in reducing cervical cancer mortality. Four rounds of cancer education and VIA screening were conducted at 24-month intervals in the screening group, whereas cancer education was offered once at entry to the control group. The study was planned for 16 years to include four screening rounds followed by four monitoring rounds. We present results after 12 years of follow-up. Poisson regression method was used to calculate the rate ratios (RRs); two-sided χ(2) was used to calculate the probability. We recruited 75360 women from 10 clusters in the screening group and 76178 women from 10 comparable clusters in the control group. In the screening group, we achieved 89% participation for screening and 79.4% compliance for diagnosis confirmation. The incidence of invasive cervical cancer was 26.74 per 100000 (95% confidence interval [CI] = 23.41 to 30.74) in the screening group and 27.49 per 100000 (95% CI = 23.66 to 32.09) in the control group. Compliance to treatment for invasive cancer was 86.3% in the screening group and 72.3% in the control group. The screening group showed a statistically significant 31% reduction in cervical cancer mortality (RR = 0.69; 95% CI = 0.54 to 0.88; P = .003). VIA screening by primary health workers statistically significantly reduced cervical cancer mortality. Our study demonstrates the efficacy of an easily implementable strategy that could prevent 22000 cervical cancer deaths in India and 72600 deaths in resource-poor countries annually.

Knowledge about virus biology is crucial for us.

Medical literature generally acknowledges that persistent infection with HPV, especially types 16 and 18, is a predisposing factor for developing cervical intraepithelial neoplasia (CIN) and cervical cancer. A similar relationship was found in penile, oropharyngeal and vulvar carcinomas. It has also been established that HPV is the most common sexually transmitted virus worldwide. WHO data shows too, that globally cervical cancer is the third most common cancer in women and is responsible for about 300 000 deaths a year [1]. For these reasons, the possible prevention of cervical cancer draws enormous interest. This has seemed to become a reality after the introduction of the HPV vaccine, which induces a cell–mediated immune response preventing HPV infection for many years [2]. The idea of using an HPV vaccine in the prevention of cervical cancer seems logical, prompting many medical and public organizations to recommend vaccination of young girls as a means of reducing the incidence of cervical cancer. Nowadays, different programs of this prevention function in more than 50 countries [3]. The study presented by Deriemaeker and colleagues in this issue of CEJU deals with the public perspective of cervical cancer and HPV vaccination, using a questionnaire in a population of Belgian students. The study, with the obvious drawback of a very low response rate (13%), is however quite interesting as it draws our attention to the very hot issue of HPV vaccination. The problem is not only with the education that we, as medical professionals should give to people, but also how politics may influence medical decisions. In the New England Journal of Medicine, Colgrave presented his study of decision–making in the US legislature concerning HPV vaccine implementation. He described that medical organizations generally support the idea, but he also claimed that opponents of HPV vaccination put up many counter arguments. The first of these was concern about the vaccine's unknown long–term side–effects. Secondly, there is the lack of long–term data proving whether the vaccination really decreases the mortality rate of cervical cancer and not only prevents HPV infection. We know that the time interval from HPV infection to the development of pre–invasive cervical lesion is 7 years and to invasive cervical carcinoma is even 25–30 years. In fact, studies showing a huge possible reduction of cervical cancer mortality and cost–effectiveness of the vaccination are very appealing, but they are only projections. Other opponents argue that the process of introducing HPV vaccination was very strongly lobbied by pharmaceutical companies [4]. There are also claims that vaccination of young girls against the sexually transmitted viral infection may promote earlier initiation of sexual activity [5]. So the study of Deriemaeker, in fact, shows the result of this educational and political debate in Belgium. The opinions of a particular population were analyzed – students, including many medical students, from an open modern society with more than 50% atheists, in a wealthy country where access to the HPV vaccine is free of charge. We may therefore assume that in this group knowledge of the problem as well as the vaccination rate will be near–optimal. Any less educated, more traditional groups from poorer populations or from countries without vaccine reimbursement would be less aware of the problem and more reluctant to vaccinate against HPV. The data showing that 82% of respondents were aware of the link between HPV and cervical cancer, and a 62% vaccination rate overall, with 82% under 21 years of age, are very encouraging So the conclusion of the study is, that in Belgium the debate in the well–educated, young part of society has been won by proponents of HPV vaccination. It is even more visible in medical students who, because of their future profession will probably confer the message to the general public On the other hand, we may suspect that much is to be done to promote HPV vaccination in other populations. It is especially important because HPV vaccination is to play a more important role in populations where other forms of cervical cancer prevention such as access to good gynecological care, and cytological screening are not so easily or widely available.

Effect of visual inspection with acetic acid (VIA) screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India.

2 Background: Cervical cancer is the most common cancer among women in developing countries and is the leading cause of cancer death in Indian women. Since cytology-based screening is not easily implementable in India, there is a need to evolve simpler alternatives. Methods: We initiated a cluster-randomized controlled trial in 1998 to investigate the efficacy of VIA screening by primary health workers (PHWs) in reducing cervical cancer mortality. Women aged 35-64 years with no prior history of cancer were included. The study was designed to include 20 clusters with an average of 7,500 eligible women per cluster. Four rounds of cancer education and VIA screening were conducted by PHWs at 24-month intervals in the screening group, while cancer education was offered once at recruitment to the control group. Recruitment was completed in March 31, 2002. Although the study was planned for 16 years, we analysed the results on the advice of the DSMC at 12 years. Results: We recruited 75,360 women from 10 clusters in the screening group and 76,178 women from 10 comparable clusters in the control group. The analysis is on an intention-to-treat basis. In the screening group, we achieved 89% participation for screening and 79% compliance for post-screening diagnostic confirmation. The quality of screening by PHWs was comparable to that of an expert gynecologist (κ=0.84). The incidence of invasive cervical cancer was 26.74 per 100,000 (95%CI: 23.41-30.74) in the screening group and 27.49 per 100,000 (95%CI: 23.66-32.09) in the control group. Compliance to treatment for invasive cancer was 86.34% in screening group and 72.29% in the control group. The screening group showed a 31% reduction in cervical cancer mortality (mortality rate ratio RR=0.69; 95%CI: 0.54-0.88; p=0.003) compared to the control group. A 7% reduction was also observed in all-cause mortality (mortality rate ratio RR=0.93; 95%CI: 0.79–1.10; p=0.41). Conclusions: VIA screening conducted by PHWs significantly reduced cervical cancer mortality. VIA screening is easily implementable and could prevent 22,000 cervical cancer deaths in India and 72,600 deaths in resource poor countries annually. Clinical trial information: NCT00632047.

Country-level correlates of cervical cancer mortality in Latin America and the Caribbean

To identify country-level correlates of geographical variations in cervical cancer (CC) mortality in Latin America and the Caribbean (LAC). CC mortality rates for LAC countries (n=26) were examined in relation to country-specific socio-economic indicators (n=58) and Human Papilloma Virus (HPV) prevalence using linear regression models. High mortality at ages <5 years, low per capita total expenditure on health, and low proportion of the population with access to sanitation were identified as the best independent predictors of CC mortality (R² =77%). In the subset of countries (n=10) with HPV prevalence estimates, these socio-economic indicators together with high-risk HPV prevalence explained almost all the between-country variability in CC mortality (R² =98%). The findings suggest that continuing socioeconomic improvements in LAC countries will be associated with further reductions in CC mortality even in the absence of organised population-based screening and vaccination programmes.

The feasibilities of TruScreen for primary cervical cancer screening: a self-controlled study

Screening programs based on cytology testing led to the incidence reduction of cervical cancer mortality of about 70-80 % in industrialized countries. However, these favorable results have not been replicated in developing areas. Thus, we aim to evaluate the efficacy of TruScreen (Polartechnics, Sydney, Australia) in detecting of precancerous lesions in comparison with cervical cytology test. A total of 181 outpatients were screened by TruScreen using the pathological results as the gold standard. The medical records of cytological smear within 6 weeks were obtained from 169 of these participants. The reliability and yield of TruScreen and cytological smear were assessed. The screening results of TruScreen were compared with those obtained from the conventional smear. The sensitivities for histologically confirmed cervical intraepithelial neoplasia (CIN) lesions by TruScreen and Pap, were 67.4 % (95 % CI 53.4-81.5) and 87.9 % (95 % CI 76.7-99.0), respectively. The specificities for histologically confirmed CIN lesions by TruScreen and Pap, were 68.1 % (95 % CI 60.3-75.9) and 74.3 % (95 % CI 70.0-81.4), respectively. In contrast to Pap smear, TruScreen was comparatively efficacious in screening of cervical cancer (χ (2) = 0.0133, P = 0.9081). TruScreen is a potential test for initial cervical screening in developing world regions.

Effectiveness of VIA, Pap, and HPV DNA Testing in a Cervical Cancer Screening Program in a Peri-Urban Community in Andhra Pradesh, India

BackgroundWhile many studies have compared the efficacy of Pap cytology, visual inspection with acetic acid (VIA) and human papillomavirus (HPV) DNA assays for the detection cervical intraepithelial neoplasia and cancer, few have evaluated the program effectiveness.Methods and FindingsA population-based sample of 5603 women from Medchal Mandal in Andhra Pradesh, India were invited to participate in a study comparing Pap cytology, VIA, and HPV DNA screening for the detection of CIN3+. Participation in primary screening and all subsequent follow-up visits was rigorously tracked. A 20% random sample of all women screened, in addition to all women with a positive screening test result underwent colposcopy with directed biopsy for final diagnosis. Sensitivity, specificity, positive and negative predictive values were adjusted for verification bias. HPV testing had a higher sensitivity (100%) and specificity (90.6%) compared to Pap cytology (sensitivity = 78.2%; specificity = 86.0%) and VIA (sensitivity = 31.6%; specificity = 87.5%). Since 58% of the sample refused involvement and another 28% refused colposcopy or biopsy, we estimated that potentially 87.6% of the total underlying cases of CIN3 and cancer may have been missed due to program failures.ConclusionsWe conclude that despite our use of available resources, infrastructure, and guidelines for cervical cancer screening implementation in resource limited areas, community participation and non-compliance remain the major obstacles to successful reduction in cervical cancer mortality in this Indian population. HPV DNA testing was both more sensitive and specific than Pap cytology and VIA. The use of a less invasive and more user-friendly primary screening strategy (such as self-collected swabs for HPV DNA testing) may be required to achieve the coverage necessary for effective reduction in cervical cancer mortality.

How to screen for cervical cancer after HPV16/18 vaccination in The Netherlands

In The Netherlands, vaccination against HPV16/18 has been recommended for all 12-year-old girls. Because screening of vaccinated women remains important, we evaluated the model-based cost-effectiveness of cervical cancer screening strategies. We considered cytology and the HPV DNA test as primary screening instrument, varied the number of screening rounds from 7 to 4, and set the screening starting age at 30 and 35 years. Our model predicted reductions in cervical cancer mortality between 60 and 81% (from 199 deaths to 37–79) when adding screening to vaccination (assumptions for vaccination: 95% efficacy, 100% compliance, lifelong protection). Screening 5 times with HPV DNA (€11,133/QALY) or 7 times with cytology (€17,627/QALY) were scenarios with comparable costs and effects and incremental cost-effectiveness ratios below the threshold in The Netherlands (€20,000 per QALY).

Decreasing Cervical Cancer Mortality in Mexico: Effect of Papanicolaou Coverage, Birthrate, and the Importance of Diagnostic Validity of Cytology

The reduction in cervical cancer mortality in developed countries has been attributed to well-organized, population-based prevention and control programs that incorporate screening with the Papanicolaou (Pap) smear. In Mexico, there has been a decrease in cervical cancer mortality, but it is unclear what factors have prompted this reduction. Using data from national indicators, we determined the correlation between cervical cancer mortality rates and Pap coverage, birthrate, and gross national product, using a linear regression model. We determined relative risk of dying of cervical cancer according to place of residence (rural/urban, region) using a Poisson model. We also estimated Pap smear coverage using national survey data and evaluated the validity and reproducibility of Pap smear diagnosis. An increase in Pap coverage (beta= -0.069) and a decrease in birthrate (beta=0.054) correlate with decreasing cervical cancer mortality in Mexico. Self-reported Pap smear rates in the last 12 months vary from 27.4% to 48.1%. Women who live in the central (relative risk, 1.04) and especially the southern (relative risk, 1.47) parts of Mexico have a greater relative risk of dying of cervical cancer than those who live in the north. There is a high incidence of false negatives in cervical cytology laboratories in Mexico; the percentage of false negatives varies from 3.33% to 53.13%. The decrease in cervical cancer mortality observed in Mexico is proportional to increasing Pap coverage and decreasing birthrate. Accreditation of cervical cytology laboratories is needed to improve diagnostic precision.

Trends in cervical cancer survival in Europe, 1983–1994: A population-based study

Objective. To evaluate trends in survival from cervical cancer in Europe and in European countries participating in the EUROCARE study as a function of age, morphology and stage at diagnosis. Methods. Relative survival and relative excess risk of death within 5 years of diagnosis, as a function of age, morphology and stage, among 73,022 women aged 15–99 years diagnosed during 1983–1994 and followed up to 1999 in each of 18 European countries participating in the EUROCARE study, using data from 34 population-based cancer registries. Results. Overall five-year relative survival was 62%, rising by 2% during the period 1983–1994. The highest survival occurred in Northern and Western Europe and the lowest in Central Europe. Survival falls with age at diagnosis, but mainly for localised disease. Survival is higher for adenocarcinoma in younger women, but higher for squamous cell carcinoma in older women. The proportions of younger women, localised cancer and adenocarcinoma all increased. The main improvements in survival were for women under 65, and for metastatic disease. Conclusions. Survival in Europe has improved slowly but steadily, but the trend is not geographically uniform. Central European countries and the UK saw little or no improvement, and survival in those countries remains the lowest among participating countries in Europe. Further reduction of cervical cancer mortality in Europe may be expected from expansion of screening, and improvement in the treatment of older women, and of metastatic disease.