Evaluation of Pre-Analytical Variables for Human Papillomavirus Primary Screening from Self-Collected Vaginal Swabs.

Human papillomavirus (HPV) primary screening is an effective approach to assessing cervical cancer risk. Self-collected vaginal swabs can expand testing access, but the data defining analytical performance criteria necessary for adoption of self-collected specimens are limited, especially for those occurring outside the clinic, where the swab remains dry during transport. Here, we evaluated the performance of self-collected vaginal swabs for HPV detection using the Cobas 6800. There was insignificant variability between swabs self-collected by the same individual (n = 15 participants collecting 5 swabs per participant), measured by amplification of HPV and human ß-globin control DNA. Comparison of self-collected vaginal swab and provider-collected cervical samples (n = 144 pairs) proved highly concordant for HPV detection (total agreement = 90.3%; positive percentage agreement = 84.2%). There was no relationship between the number of dry storage days and amplification of HPV (n = 68; range, 4 to 41 days). Exposure of self-collected dry swabs to extreme summer and winter temperatures did not affect testing outcomes. A second internal control (RNase P) demonstrated that lack of amplification for ß-globin from self-collected specimens was consistent with poor, but not absent, cellularity. These data suggest that self-collected vaginal samples enable accurate clinical HPV testing, and that extended ambient dry storage or exposure to extreme temperatures does not influence HPV detection. Furthermore, lack of ß-globin amplification in HPV-negative samples accurately identified participants who required recollection.

Outcomes of Robotic Hysterectomy for Treatment of Benign Conditions: Influence of Patient Complexity.

INTRODUCTION: Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach. OBJECTIVE: To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time. METHODS: In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume. RESULTS: The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients. CONCLUSION: For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications.

Preservation of fertility after partial resection of bilateral ovarian cystadenofibromas: a case report.

BACKGROUND: Benign cystadenofibromas and adenofibromas may represent precursors to malignant lesions. CASE: A 20-year-old woman undergoing infertility treatment was found to have cystadenofibromas involving both ovaries, with no separable normal ovarian tissue visible. Because complete resection of the tumors would have required bilateral oophorectomy, the tumors were only partially resected using a shave technique. This patient subsequently had 3 normal-term deliveries over 7 years and did not have any clinically significant regrowth of her tumors during this time. CONCLUSION: It may be reasonable to delay removing benign tumors in a young woman who has not completed her childbearing.

On maintaining the balance.

Recent studies have shown an association of loop electrocautery excision procedure (LEEP) with subsequent obstetric complications, including preterm birth. These data necessitate a reevaluation of how LEEP is used, particularly in cases where the presence of a high-grade lesion has not been established. In the 2001 consensus guidelines, nonadolescent women with high-grade cytology and subsequent negative colposcopy and endocervical curettage are recommended to undergo LEEP for further evaluation. Given the new information on potential obstetric complications and the rising age of childbearing, it is debatable whether the benefits of LEEP in this situation truly outweigh the risks for all women, regardless of age, who have not completed childbearing. We urge the committee charged with revising the guidelines to carefully consider this issue.

Use of raloxifene among women with a history of breast cancer.

PURPOSE: To examine raloxifene use among women with a history of breast cancer. METHODS: Kaiser Permanente tumor registry and membership files were used to identify women diagnosed with breast cancer after 1994 who were health plan members in 1998 or later, when raloxifene became available. Information on raloxifene treatment was obtained from computerized pharmacy records. Treatment patterns were examined and the characteristics of those who did and did not receive raloxifene were compared. RESULTS: Among the 17,968 women with a history of breast cancer, 711 (4.0%) had at least one prescription for raloxifene. Use among these women was more common than among similarly aged women in the health plan without a history of breast cancer, especially among those less than age 60 years. Among women with a history of breast cancer, raloxifene users were more than twice as likely as non-users to have had a bone mineral density test (60 versus 26%, p<0.0001) and, if tested, were more likely to have osteopenia or osteoporosis (80 versus 63%, p<0.0001). Compared to non-users, users had earlier stage breast cancer at diagnosis (80% versus 71% with local disease, p<0.0001). Raloxifene use was largely restricted to women whose initial breast cancer had not been treated with adjuvant tamoxifen or who had received less than 5 years of tamoxifen therapy. CONCLUSION: In this setting, raloxifene use among women with a history of breast cancer is related to stage at diagnosis and bone mineral density and is rare among women who have completed a 5-year course of adjuvant tamoxifen.