PAX1 and SEPT9 methylation analyses in cervical exfoliated cells are highly efficient for detecting cervical (pre)cancer in hrHPV-positive women.

Studies have investigated PAX1 and SEPT methylation were closely associated with cervical cancer. For this study, we verified the expressions of PAX1 and SEPT9 methylation in 236 hrHPV women cervical exfoliated cells by using quantitative methylation-specific PCR and we further explored their diagnostic value in cervical (pre)cancer detection. Our results identified that the methylation rates and levels of PAX1 and SEPT9 increased with cervical lesion severity. For a diagnosis of cervical (pre)cancer, the area under the curve (AUC) of PAX1 methylation was 0.77 (95% CI 0.71-0.83) and the AUC of SEPT9 methylation was 0.86 (95% CI 0.81∼0.90). Analyses of the PAX1 and SEPT9 methylation statuses alone or combined with commonly used tests can efficiently identify cervical (pre)cancer. In particular, SEPT9 methylation might serve as an effective and powerful biomarker for the diagnosis of cervical (pre)cancer and as an alternative triage test in HPV-based cervical (pre)cancer screening programs.Impact StatementWhat is already known on this subject? This subject showed that PAX1 and SEPT9 methylation were closely associated with cervical cancer. The methylation rates and levels of PAX1 and SEPT9 increased with cervical lesion severity and reached a peak in cervical cancer exfoliated cells. We further assessed the diagnostic performances of PAX1 and SEPT9 methylation in cervical cancer screening. In detecting cervical (pre)cancer, the sensitivity values of PAX1 and SEPT9 methylation were up to 61.18% and 82.35%, respectively, and the specificity values of PAX1 and SEPT9 methylation were up to 95.36% and 86.75%, respectively. Moreover, the ROC curve analysis showed AUC values of 0.77 for PAX1 methylation and 0.86 for SEPT9 methylation tests, which were significantly superior to other commonly used tests. These findings suggest that PAX1 and SEPT9 methylation detection may have great clinical potential in cervical cancer screening.What the results of this study add? The rates and levels of PAX1 and SEPT9 methylation increased with the severity of the cervical lesions. For a diagnosis of cervical (pre)cancer, the area under the curve (AUC) of PAX1 methylation was 0.77 (95% CI 0.71-0.83), and the sensitivity and specificity values were 61.18% and 95.36%, respectively. The AUC value of the SEPT9 methylation was 0.86 (95% CI 0.81 ∼ 0.90), and the sensitivity and specificity values were 82.35% and 86.75%, respectively. Compared with the various tests we conducted, the PAX1 methylation showed the highest specificity (95.36%), and the SEPT9 methylation demonstrated the highest accuracy(86.00%).What the implications are of these findings for clinical practice and/or further research? The methylation levels of PAX1 and SEPT9 had a certain predictive effect on the severity of cervical lesions in hrHPV-positive women. In addition, SEPT9 methylation analysis performs better than PAX1 methylation analysis and commonly used tests in cervical exfoliated cells for detecting cervical (pre)cancer in hrHPV-positive women. SEPT9 methylation analysis merits consideration as an effective and objective, alternative triage test in HPV-based cervical (pre)cancer screening programs.

Support for lowering cervical cancer screening age to 25 for women living with HIV: retrospective cross-sectional programmatic data from Botswana.

BACKGROUND: Women living with human immunodeficiency virus (HIV) tend to develop cervical cancer at a younger age than women without HIV. The World Health Organization's (WHO) 2021 guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention include a conditional recommendation for initiating screening at age 25 for women living with HIV (WLWH). This recommendation is based on low-certainty evidence, and WHO calls for additional data. We describe the association of age and HIV status with visual inspection with acetic acid (VIA) positivity and cervical intraepithelial neoplasia grade two or higher (CIN2+) in Botswana. METHODS: This was a retrospective cross-sectional study of 5714 participants aged 25 to 49 years who underwent VIA screening in a clinic mainly serving WLWH. VIA-positive women received cryotherapy if eligible or were referred for colposcopy and excisional treatment. Known cervical cancer risk factors, screening outcome, and histological results were extracted from the program database. We compared the proportions and association of VIA positivity and CIN2+ by age and HIV status. RESULTS: The median age was 35 years [IQR 31-39], and 18% of the women were aged 25-29. Ninety percent were WLWH; median CD4 count was 250 cells/µL [IQR 150-428], and 34.2% were on anti-retroviral treatment (ART). VIA-positivity was associated with younger age (OR 1.48, CI 1.28, 1.72 for 25-29 years vs. 30-49 years), and HIV-positivity (OR 1.85, CI 1.51, 2.28). CIN2+ was only associated with HIV-positivity (OR 6.12, CI 3.39, 11.10), and proportions of CIN2+ were similar for both age groups in WLWH (69.1% vs. 68.3%). CONCLUSIONS: Younger WLWH in Botswana had a significant burden of CIN2+. This finding further supports lowering the screening age for WLWH from 30 to 25.

The Dysregulation of MicroRNAs in the Development of Cervical Pre-Cancer-An Update.

Globally in 2020, an estimated ~600,000 women were diagnosed with and 340,000 women died from cervical cancer. Compared to 2012, the number of cases increased by 7.5% and the number of deaths increased by 17%. MiRNAs are involved in multiple processes in the pathogenesis of cervical cancer. Dysregulation of miRNAs in the pre-stage of cervical cancer is the focus of this review. Here we summarize the dysregulated miRNAs in clinical samples from cervical pre-cancer patients and relate them to the early transformation process owing to human papillomavirus (HPV) infection in the cervical cells. When HPV infects the normal cervical cells, the DNA damage response is initiated with the involvement of HPV's E1 and E2 proteins. Later, cell proliferation and cell death are affected by the E6 and E7 proteins. We find that the expressions of miRNAs in cervical pre-cancerous tissue revealed by different studies seldom agreed with each other. The discrepancy in sample types, samples' HPV status, expression measurement, and methods for analysis contributed to the non-aligned results across studies. However, several miRNAs (miR-34a, miR-9, miR-21, miR-145, and miR-375) were found to be dysregulated across multiple studies. In addition, there are hints that the DNA damage response and cell growth response induced by HPV during the early transformation of the cervical cells are related to these miRNAs. Currently, no review articles analyse the relationship between the dysregulated miRNAs in cervical pre-cancerous tissue and their possible roles in the early processes involving HPV's protein encoded by the early genes and DNA damage response during normal cell transformation. Our review provides insight on spotting miRNAs involved in the early pathogenic processes and pointing out their potential as biomarker targets of cervical pre-cancer.

Detection of Cervical Precancer Using Visual Inspection Method with Acetic Acid.

BACKGROUND: Cervical cancer screening is the priority activity of the government. Visual inspection with Acetic acid (VIA), Pap smear Liquid-based cytology, and HPV DNA testing are different methods of screening. VIA-based screening is the cost-effective method of screening in a resource-constrained setting like in our country as this doesn't require cyto-histological testing, can be performed by trained paramedics too, and is as accurate as a cytological test. The aim is to explore pre-cancer cervical lesions by screening women in the community by visual inspection using acetic-acid. METHODS: Community-based cross-sectional study done at a health camp setting for three months from March to June 2023. The married non-pregnant women of 30-60 years were screened. Descriptive tests as well as sub-group analysis performed by Chi-Square tests. RESULTS: From ten community health camps, 1255 cases were screened and screen positivity was 14.3%. Positive results were proportionately distributed to all parity by 13-19%. Half of the positive results (47.2%) were in the 34-40 age group. There were no significant differences in screen positivity by parity or vaginal discharge. Menopausal women had 7.7% screen positivity. CONCLUSIONS: The prevalence of VIA positivity in the community was found double the previous facility-based prevalence; and there was no significant difference by parity, menopausal status, and vaginal discharge. The positivity was more in 30-45 years of age.

Cervical pre-cancer screening by visual inspection of the cervix after application of acetic acid in rural Burkina Faso: evaluation of women's knowledge, screening practice habits, acceptability and prevalence of risk factors and lesions in Boussé health district.

Introduction: cervical cancer is a major public health problem among women in sub-Saharan Africa. The disease can be controlled through early diagnosis through simple cost-effective methods such as visual inspection of the cervix after application of acetic acid or lugol´s iodine. However, screening for cervical cancer is still underused particularly in rural areas of Burkina Faso. The objective was to estimate the prevalence of cervical pre-cancer cancer in rural health district of Boussé, Burkina Faso. Methods: we conducted a cross-sectional study in the health district of Boussé in Northern-Central Burkina Faso from July to August 2014. Women aged 23-50 years were interviewed about their knowledge of cervical cancer and their screening practice and subsequently screened for cervical cancer by VIA. Results: a total of 418 participants were included with a median age of 34 years IQR (30-40 years). Two2 hundred participants (48%) had never heard about cervical cancer. About 134 participants (32%) knew at least one risk factor of cervical cancer. Only 37 women (9%) reported ever being screened for cervical cancer. Twenty-two percent reported concurrent sexual partnerships. The majority of the women (92%) are willing to pay to get screened for cervical pre-cancer by VIA. Overall, 21 participants (5%) were diagnosed with a cervical lesion by VIA and all of them accepted treatment with Loop electro surgical procedure. Conclusion: screening by VIA is feasible in rural Burkina Faso, but there is a poor knowledge on cervical cancer amongst the women. There is a need to set up a comprehensive, systematic, affordable and efficient cervical cancer program including an information campaign and making screening accessible in rural remote areas.

Natural and synthetic drugs and formulations for intravaginal HPV clearance.

BACKGROUND: Except for a few preventative Human Papillomavirus (HPV) vaccines, there is currently no cure for HPV infection. There are a number of cutting-edge strategies and potent medications or herbal formulations that can be applied topically for early clearance of HPV infection before HPV DNA gets integrated into host cell genome. This is facilitated due to cervical cancer having distinct and well-recognized long precancerous stages. OBJECTIVES: This review aims to outline every possible medication and formulation, both natural and synthetic, that can be applied topically as intravaginal application to help remove HPV infection at an early precancerous stage. RESULTS: Several anti-HPV/HPV clearance compounds and formulations for high-grade lesions are undergoing clinical trials. However, the majority of compounds are still in the early stages of development and require additional research to become viable HPV clearance candidates. Synthetic drugs may be more promising because they may have a more targeted effect; however, they may also have significant adverse effects. On the other hand, natural medications are safer to use. They are less specific, but have minimal to no adverse effects. CONCLUSIONS: This article may serve as a valuable resource of information for managing and preventing precancerous carcinogenic HPV infections. Research could be directed toward developing candidate drugs to make evidence-based decisions about advancing them to clinical trials and, eventually, to the market for potential use in the prevention and control of cervical cancer, which is almost always preventable or even curable if detected early.

A community-based cervical cancer screening program in Alappuzha district of Kerala using camp approach.

Background: Cervical cancer is a major cause of preventable cancer related death in women, particularly in middle-income developing countries. Screening of cervical pre-cancer by cytology remains an effective strategy for prevention of mortality. However, there is paucity of community-based studies in Kerala. The aim of this study was to determine the prevalence of cervical precancerous lesions and to study the associated epidemiological factors through camp approach. Materials and Methods: A cross-sectional study was carried out among women in Alappuzha district, Kerala, by conducting community-based screening camps covering all the panchayaths from February 2017 to January 2019. Statistical Analysis Used: Descriptive statistics including mean for continuous variables and frequency along with their percentage for categorical variables were determined. Pearson's Chi-square test was used to determine the strength of the association between variables. Statistical significance was set at P value less than 0.05. Results: Out of 5241 women screened, majority (62.9%) were in the reproductive age group (31-50 years) with mean age of 47.1 ± 10.3 years. The prevalence of precancerous lesions of cervix was 6.37%, which consisted of low-grade squamous intraepithelial lesion (LSIL) in 2.2%, high-grade squamous intraepithelial lesion (HSIL) in 0.5% and Carcinoma-in-situ in 0.2%. Risk factors that had significant association with cervical precancerous lesions were lower education status, genital infections, early marriage age and high parity. Conclusion: Well planned community-based screening programs can help to identify the exact prevalence of cervical pre-cancer in a region and the associated epidemiological factors leading to formulation of effective elimination strategies.

Cervical Cancer Prevention in El Salvador: Gains to Date and Challenges for the Future.

Cervical cancer is preventable through vaccination, early detection, and the treatment of pre-cancerous lesions. However, global inequalities mean that the disease remains a leading cause of cancer death around the world, with over 80% of new cases and 90% of deaths occurring in low- and middle-income countries (LMICs). In El Salvador, joint efforts between the Ministry of Health (MoH) and the non-profit organization Basic Health International (BHI) have been in place since 2008, with the goal of reducing the country's disease burden. While the World Health Organization's (WHO) call to action to eliminate cervical cancer provided worldwide momentum to implement new public health initiatives, the COVID-19 pandemic disrupted ongoing programs and jeopardized plans for the future. The purpose of this manuscript is to describe the progress that El Salvador has achieved in improving cervical cancer prevention, the impact of the pandemic on current strategies, and potential solutions that can help the country meet the WHO's strategic targets by 2030 to accelerate the elimination of cervical cancer.

Influence of Demographic and Reproductive Factors on Cervical Pre-Cancer and Cancer in Bangladesh.

BACKGROUND: In Bangladesh, cervical cancer (CC) is the 2nd most common cancer with estimated 8068 new cases and 5,214 deaths every year. It is also revealed that different socio-demographic factors have association with CC. This study was performed to evaluate the colposcopy outcomes and the association of different demographic and reproductive risk factors with cervical pre-cancer and cancer. METHODS: This retrospective cross-sectional study was carried out at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) between January 2010 and December 2016. RESULTS: A total 16147 women attended the colposcopy clinic of BSMMU with VIA positive reports. Among them, 65.73% women were referred from different VIA centers of Dhaka district. Mean age of marriage of the subjects was 16. 93 (± 1) and mean age of 1st delivery was 18.45 years (± 4.10). Almost three-fourth of them were married before 18 years and had their 1st delivery by 20 years. Colposcopy examination of the VIA positive women revealed that 36.7% had CINI, 10.6% had CINII/ III and 7.1% had carcinoma of cervix. Considering CIN as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 99.7%, 75.3%, 70.3% and 99.8% respectively. On other hand considering CIN2+ as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 73.8%, 92.7%, 64.4% and 95.2% respectively. Statistical analysis revealed that higher age (p=0.000), lower level of education (p=0.007), lower socioeconomic status (p=0.014), higher parity (p=0.001) had individual influence on cervical pre-cancer and cancer. CONCLUSIONS: This study indicated higher age, low level of education, lower socio-economic condition and higher parity as most important socio-demographic factors for developing cervical pre-cancer and cancer in Bangladesh.

The potential of biobanked liquid based cytology samples for cervical cancer screening using Raman spectroscopy.

Patient samples are unique and often irreplaceable. This allows biobanks to be a valuable source of material. The aim of this study was to assess the ability of Raman spectroscopy to screen for histologically confirmed cases of Cervical Intraepithelial neoplasia (CIN) using biobanked liquid based cytology (LBC) samples. Two temperatures for long term storage were assessed; 80°C and -25°C. The utility of Raman spectroscopy for the detection of CIN was compared for fresh LBC samples and biobanked LBC samples. Two groups of samples were used for the study with one group associated with disease (CIN 3) and the other associated with no disease (cytology negative). The data indicates that samples stored at -80°C are not suitable for assessment by Raman spectroscopy due to a lack of cellular material and the presence of cellular debris. However, the technology can be applied to fresh LBC samples and those stored at -25°C and is, moreover, effective in the discrimination of negative samples from those where CIN 3 has been confirmed. Pooled fresh and biobanked samples are also amenable to the technology and achieve a similar sensitivity and specificity for CIN 3. This study demonstrates that cervical cytology samples stored within biobanks at temperatures that preclude cell lysis can act as a useful resource for Raman spectroscopy and will facilitate research and translational studies in this area.

The potential of RNA as a target for national screening of pre-cancer.

Whole national screening of pre-cancer is done only in some few countries, dominated by The Netherlands, Denmark, UK, Norway and Finland. These national screenings are done combining national cancer registry, national public health and national medical bodies or hospitals. Until some few years ago national screening was only done using morphological or visual methods or technology. Today a number of molecular methods have been implemented to serve these national screening programs. Based on all the discussions within this review, it is clear that the main driving engine and the cause of cervical pre-cancer and the main cause of invasive cervical cancer is the expression of E6 and E7 oncoproteins from HPV 16, 18, 31, 33 and 45. However, the main challenge is the role of morphology or imaging-based diagnosis in the original definition of pre-cancer disease. This definition is not based on the cause of cervical precancer but based on a complex, subjective, morphological observations. The difference between these two definitions are discussed in this review. The unique discovery done while validating the first standardized detection technology used against mRNA, confirmed that the presence of both abnormal E6 and/or E7 mRNA and protein is the cause of cervical pre-cancer or severe neoplasia and the main cause of invasive cervical cancer. This confirmation was evident even though all these studies were disturbed by the above defined biases from morphology or imaging-based diagnosis. The use of the screening target that cause stable and high expression of the most carcinogenic compounds ever discovered, must cause a more accurate screening program. A number of studies have proved that the detection of E6/E7 mRNA followed-up by indirect or direct treatment in a well-organized national screening program, would reduce the incidence of cervical cancer. This review discusses the main studies involved in the scientific, clinical evaluation and how this unique technology could be used as a new medical gold standard for national screening of cervical pre-cancer.

Clinical implications of the interaction between HPV and HIV infections.

HIV-related immunodeficiency has complex effects on female genital HPV, which include increased risks of infection, multiple types, persistence, reactivation and the risk to develop pre-invasive and invasive disease. Reconstitution of immunity with anti-viral drugs improves cellular immunity, but the risk of HPV-related malignancy remains higher than background incidences and presents at younger ages. Early initiation of antiretroviral therapy (ART) allows improved retention of immune memory through existing antibodies and T-cell clones and improves long-term outcomes. Suggestions of a higher risk to contract HIV if there is existing genital HPV infection are supported and explained by pathophysiological cervical changes, including inflammation. HIV-HPV interactions should influence public health decisions towards prioritising large-scale prepubertal HPV-vaccine roll-out, secondary cervical cancer prevention and early detection programmes for HIV-infected women and early initiation of ART. This chapter will also focus on special considerations for the management of women with co-infection with these two viruses and genital HPV-related diseases.