Self-sampling HPV test in women not undergoing Pap smear for more than 5 years and factors associated with under-screening in Taiwan.

BACKGROUND/PURPOSE: Under-utilization of Papanicolaou (Pap) smear causes a gap in the prevention of cervical neoplasms. A prospective population-based study was conducted investigating whether a self-sampling human papillomavirus (HPV) test was feasible for under-users of Pap smear and factors associated with under-screening in Taiwan. METHODS: Women not having Pap smear screening for > 5 years were invited to participate in this study. Invitation letters and educational brochures were mailed to 4% of randomly selected eligible women from Taoyuan City, Taiwan, and responders received an HPV self-sampling kit. Those with HPV-positive results were recalled for a Pap smear and colposcopy. RESULTS: Between March 2010 and June 2012, 10,693 women were invited, 354 responded (3.3%), and 282 (2.6%) gave valid informed consent, answered the questionnaire, and submitted HPV samples. The median age of enrolled women was 48.1 years. Forty-seven women (16.7%) had a positive HPV test, and 14 women accepted further survey to find two CIN2+. Another two cases of CIN2+ were identified from a national registry database. The cost of direct mailing self-samplers was less than that done on request (from NT$434,866 to NT$164,229, response rate of 5% to 15%, respectively, versus NT$683,957 for detecting 1 CIN2+). Reasons for not attending screening included lack of time, embarrassment, assumed low risk, fear of positive results, and perceived potential pain. Among the responders, 90.8% found the method acceptable. CONCLUSION: Our study indicated that different approaches (e.g., direct mailing self-samplers to under-users and/or various educational interventions) must be explored to improve coverage in populations with culture characteristics similar to Taiwan.

Human papillomavirus genotype in cervical intraepithelial neoplasia grades 2 and 3 of Taiwanese women.

We aimed to assess the distribution of human papillomavirus (HPV) genotypes in high-grade cervical lesions in Taiwan. The study included 1,086 paraffin-embedded, formaldehyde-fixed cervical intraepithelial neoplasia (CIN) 2/3 specimens. HPV genotyping was performed using polymerase chain reaction (PCR)-based methods. Multiple HPV types were validated by E6 type-specific PCR, direct sequencing and/or real-time PCR. HPV DNA was detected in 995 (91.6%) specimens, and multiple HPV types were identified in 192 (19.3%) samples. The leading HPV types were HPV16 (24%), HPV52 (20%), HPV58 (20%), HPV33 (13%), HPV31 (8%) and HPV18 (4.6%). Although the leading six types consisted of 87.6%, HPV16 or 18 comprised only 30.9%. The prevalence of different HPV types showed a significant association with age. In women older than 50 yr, HPV16 and 18 comprised 21.3% (83/389), while HPV52, 58 and 33 represented 55.5% (216/389). In women aged less than 50 yr, HPV16 and 18 comprised 32.1% (224/697, p < 0.0001), while HPV 52, 58 and 33 represented 47.9% (334/697, p = 0.02). The distribution of HPV genotypes was compared with previously reported findings for Taiwanese women with cervical cancer (CC). The overall HPV16 positivity rate was significantly higher in CC than in CIN 2/3 (odds ratio: 2.14, 95% CI: 1.91-2.40). In addition, HPV18, 39 and 45 were significantly overrepresented in CC, whereas HPV52, 58, 33, 31, 35, 51 and 53 were underrepresented. We concluded that an effective vaccine against the most common HPV types could prevent a significant proportion of cervical cancer cases that occur in Taiwan.

An exploration of Papanicolaou smear history and behavior of patients with newly diagnosed cervical cancer in Taiwan.

BACKGROUND: Papanicolaou (Pap) smear is an effective preventive measure in reducing cervical cancer incidence and mortality. The national health insurance made free annual cervical screening available to all Taiwanese women 30 years or older. OBJECTIVE: The objective of this study was to increase knowledge about Pap smear screening history, attitudes, and behavior in Taiwanese women with newly diagnosed cervical cancer. METHODS: One hundred forty-one women with newly diagnosed cervical cancer were prospectively enrolled between January 2007 and June 2008. Data were collected via a questionnaire survey, which included (1) demographic and socioeconomic characteristics, (2) reasons for receiving or not receiving a Pap smear test, and (3) knowledge of and sources of information on Pap smears. RESULTS: Of the 141 patients, 62 (44.0%) had never had a Pap smear before diagnosis, 10 (7.1%) did not know about the Pap smear, and only 30 (21%) reported having had more than 3 Pap smears in their lifetime. Stepwise logistic regression identified perceived potential pain, fear of embarrassment, and the number of sexual partners of the male consort as independently associated with the number of previous Pap smears (0 vs > or =1). CONCLUSION: Our results highlight the need for a better understanding of women's knowledge and experiences with Pap smear screening and developing more comfortable methods of cervical cancer screening. IMPLICATIONS FOR PRACTICE: Education strategies should be focused on improving access to never-users. The need for a better understanding of women's experiences with Pap smear screening is highlighted.

Incidence and outcome of acquisition of human papillomavirus infection in women with normal cytology--a population-based cohort study from Taiwan.

Little is known about acquisition of human papillomavirus (HPV) and its outcome among older women with negative HPV testing and normal cytology. A longitudinal 3-yr follow-up of nested-cohort subjects (n = 8825) from a population-based cervical cancer screening study whose Pap and HPV tests were negative at baseline were conducted. Every active HPV-negative (n = 413) participant had 12-mo follow-ups of Pap smear and HPV testing. Colposcopy was performed if either HPV-positive or cytology was abnormal. The cytology and histology information of the remaining subjects (passive HPV-negative, n = 8412) was obtained from national registry database. Median age of participants was 45 yr (range, 30-73 yr). The incidence of new acquisition was 4.2/100 woman-years. The 3-yr cumulative total HPV acquisition rate was 11.1% (95% confidence interval [CI]: 8.1-14.1). Increased number of sexual partners (> or =2 vs. 1) of the participant was associated with risk of acquisition (odds ratio [OR]: 5.0, 95% CI: 2.0-12.6) by multivariate analysis. Three cases of > or = cervical intraepithelial neoplasia (CIN) 2 were identified in 3-yr follow-up in active HPV-negative subjects. HPV genotypes in the dysplastic tissue were actually present at baseline samples after reanalysis. From the passive HPV-negative group, only 1 case progressed to CIN2 probably after HPV acquisition. Negative Pap and HPV tests assured a very low risk of developing > or = CIN2 within 3 yr despite incident HPV infection.

Host and viral factors in relation to clearance of human papillomavirus infection: a cohort study in Taiwan.

Human papillomavirus (HPV) persistence is essential for cervical cancer development. We accrued nested-cohort subjects from a population-based study to investigate the host and viral factors related to outcome of HPV infection. Women (age > or = 30 years old) with HPV-positive but normal cytology and negative colposcopy were invited to participate. After signing informed consent, every participant completed a structured questionnaire and had 6-monthly follow-ups of Pap smear, HPV testing and colposcopy. Total and type-specific HPV clearance rates as well as host and viral factors associated with clearance in 3-year longitudinal follow-up were analyzed. Adjusted hazard ratios (HRs) of progression to > or = cervical intraepithelial neoplasia (CIN) 2 according to baseline HPV of the women with normal cytology were calculated from national registry database. Among the 626 eligible women, 526 (median age 47, 29-75) were enrolled and 412 returned for follow-up at least once. The median follow-up of enrolled subjects was 23 months (range 6.8-39). The 3-year cumulative total HPV clearance rate was 49.0% (95% confidence interval [CI]: 43.3-54.7%). The median 3-year cumulative type-specific HPV clearance rate was 50.0% (range 0-100.0%) with a median time to clearance of 12.4 months (6.4-24.5). Older age was associated with significantly decreased total HPV clearance and decreased type-specific clearance in HPV-18 and -53, while high viral load was associated with decreased total and type-specific clearance. After adjusting confounding variables, the HR of developing > or =CIN2 in baseline HPV-positive women was 34.0-fold (95% CI: 15.5-74.7) as compared to HPV-negative women.

Positron emission tomography in evaluating the feasibility of curative intent in cervical cancer patients with limited distant lymph node metastases.

OBJECTIVE: Clinical outcomes of cervical cancer patients with distant lymph node (LN) metastases are poor. [(18)F] fluorodeoxyglucose positron emission tomography (PET) or PET/computed tomography (CT) scans could potentially benefit treatment plan. METHODS: Patients with cervical cancer whose CT/magnetic resonance imaging (MRI)-based imaging showed limited metastases to para-aortic lymph node (PALN), inguinal (ILN), and/or supraclavicular (SLN) were prospectively enrolled to evaluate whether PET or PET/CT influenced management. The clinical impact of PET or PET/CT was determined on a patient basis. RESULTS: Between November 2001 and April 2007, 47 patients were enrolled for suspected metastasis to PALN with (n=8) or without other distant nodal involvement (n=31), ILN (n=6), or SLN metastasis (n=2). Additional PET or PET/CT had positive clinical impact in 21 (44.7%) of the 47 study patients, 23 had no impact, and three had negative impact. Positive impact included disclosing additional curable sites (n=8), down-staging (n=6), offering metabolic biopsy (n=4) or change to palliation (n=3). The 2-year overall survival (OS) of the study patients was 56.9% with median follow-up time of 47.0 months (range: 8-71 months) in surviving patients. The 2-year OS rates for PALN (based on histology or CT/MRI-PET consensus) and histology-proven SLN metastasis were 50.6% and 24.7%, respectively. Two (40.0%) of the five patients with histology-proven ILN metastases had no evidence of disease. CONCLUSIONS: PET or PET/CT added benefit to primary treatment planning in cervical cancer with MRI-defined suspected distant nodal metastasis.