RESUMEN
OBJECTIVE: An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth. DATA SOURCES: We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages. STUDY ELIGIBILITY CRITERIA: All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included. METHODS: Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival. RESULTS: Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies. CONCLUSION: This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.
Asunto(s)
Cerclaje Cervical , Complicaciones del Embarazo , Nacimiento Prematuro , Recién Nacido , Embarazo , Femenino , Humanos , Lactante , Embarazo Gemelar , Cerclaje Cervical/efectos adversos , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/prevención & control , Nacimiento Prematuro/etiología , Cuello del ÚteroRESUMEN
INTRODUCTION: Immunostaining with p16INK4a (p16), a tumor-suppressor surrogate protein biomarker for high-risk human papillomavirus (hrHPV) oncogenic activity, may complement standard hematoxylin and eosin (H&E) histology review, and provide more objective criteria to support the cervical intraepithelial neoplasia (CIN) diagnosis. With this study we assessed the impact of p16 immunohistochemistry on CIN grading in an hrHPV-based screening setting. MATERIAL AND METHODS: In this post-hoc analysis, 326 histology follow-up samples from a group of hrHPV-positive women were stained with p16 immunohistochemistry. All H&E samples were centrally revised. The pathologists reported their level of confidence in classifying the CIN lesion. RESULTS: Combining H&E and p16 staining resulted in a change of diagnosis in 27.3% (n = 89) of cases compared with the revised H&E samples, with a decrease of 34.5% (n = 18) in CIN1 and 22.7% (n = 15) in CIN2 classifications, and an increase of 18.3% (n = 19) in no CIN and 20.7% (n = 19) in CIN3 diagnoses. The level of confidence in CIN grading by the pathologist increased with adjunctive use of p16 immunohistochemistry to standard H&E. CONCLUSIONS: This study shows that adjunctive use of p16 immunohistochemistry to H&E morphology reduces the number of CIN1 and CIN2 classifications with a proportional increase in no CIN and CIN3 diagnoses, compared with standard H&E-based CIN diagnosis alone. The pathologists felt more confident in classifying the material with H&E and p16 immunohistochemistry than by using H&E alone, particularly during assessment of small biopsies. Adjunctive use of p16 immunohistochemistry to standard H&E assessment of CIN would be valuable for the diagnostic accuracy, thereby optimizing CIN management and possibly decreasing overtreatment.
Asunto(s)
Alphapapillomavirus , Infecciones por Papillomavirus , Displasia del Cuello del Útero , Neoplasias del Cuello Uterino , Femenino , Humanos , Inmunohistoquímica , Inhibidor p16 de la Quinasa Dependiente de Ciclina/análisis , Inhibidor p16 de la Quinasa Dependiente de Ciclina/metabolismo , Hematoxilina , Eosina Amarillenta-(YS) , Neoplasias del Cuello Uterino/patología , Biomarcadores de Tumor/metabolismo , Alphapapillomavirus/metabolismo , Papillomaviridae , Displasia del Cuello del Útero/patologíaRESUMEN
OBJECTIVE: HPV16/18 genotyping and detection of hypermethylation of human cell genes involved in cervical oncogenesis have shown promising results in triage of high-risk HPV (hrHPV)-screen positive women on cervical smears. These tests can be performed on self-samples, which contain cervical and vaginal cells. We studied whether a self-sample represents the hrHPV type causing the worst cervical lesion and whether any differences in hypermethylation of FAM19A4/miR124-2 exist between CIN lesions caused by different hrHPV types. These results have important implications for reflex triage of self-samples. METHODS: Correlation between genotype found on self-sample using GP5+/6+-PCR-EIA-LMNX and causative hrHPV genotype in the worst lesion on histology was studied using laser capture microdissection (LCM)-SPF10-PCR (Nâ¯=â¯152). Hypermethylation of FAM19A4/miR124-2 in the self-sample was tested in a quantitative methylation specific PCR and compared between lesions caused by HPV16/18 and other hrHPV genotypes. RESULTS: Causative hrHPV genotype of the worst lesion (CIN1, CIN2, CIN3, invasive cervical cancer) was detected on self-sample in 93.4%. HPV16 was the most frequently found genotype on self-sampling (39.2%, 73/186) and causative genotype in CIN3+ (51.4%, 38/74, all detected on self-sample). There were no differences in the percentages of positive FAM19A4/miR124-2 methylation assays between lesions caused by HPV16/18 (73.8% in CIN3+) or other hrHPV genotypes (66.7% in CIN3+) (pâ¯=â¯0.538). CONCLUSIONS: Our results show that hrHPV genotypes found on self-sample were a good representation of hrHPV in the worst CIN lesion and that methylation testing on self-sample for detection of CIN3+ was not significantly different between lesions caused by HPV16/18 and other hrHPV genotypes.
Asunto(s)
Citocinas/metabolismo , Papillomavirus Humano 16/genética , Papillomavirus Humano 18/genética , MicroARNs/metabolismo , Infecciones por Papillomavirus/virología , Displasia del Cuello del Útero/virología , Neoplasias del Cuello Uterino/virología , Adulto , Biopsia , Citocinas/genética , Metilación de ADN , Femenino , Genotipo , Humanos , Captura por Microdisección con Láser , MicroARNs/genética , Persona de Mediana Edad , Infecciones por Papillomavirus/genética , Infecciones por Papillomavirus/metabolismo , Infecciones por Papillomavirus/patología , Neoplasias del Cuello Uterino/genética , Neoplasias del Cuello Uterino/metabolismo , Neoplasias del Cuello Uterino/patología , Displasia del Cuello del Útero/genética , Displasia del Cuello del Útero/metabolismo , Displasia del Cuello del Útero/patologíaRESUMEN
The aim of this study was to evaluate the clinical utility of p16/Ki-67 dual staining, for the identification of CIN in high-risk HPV-positive women from a non-responder screening cohort. P16/Ki-67 dual staining, Pap cytology, and HPV16/18 genotyping were performed on physician-taken liquid-based samples from 495 women who tested high-risk HPV positive on self-sampled material (PROHTECT-3B study). Different triage strategies involving p16/Ki-67 dual staining were evaluated for sensitivity, specificity, and predictive value for ≥CIN2 and ≥CIN3, and compared to Pap cytology with a threshold of atypical cells of undetermined significance. Centrally revised histology or an adjusted endpoint with combined high-risk HPV negative and cytology negative follow-up at 6 months was used as gold standard. Pap cytology (threshold atypical cells of undetermined significance) triage of high-risk HPV-positive samples showed a sensitivity of 93% (95% confidence interval: 85-98) with a specificity of 49% (95% confidence interval: 41-56) for ≥CIN3. Three triage strategies with p16/Ki-67 showed a significantly increased specificity with similar sensitivity. P16/Ki-67 triage of all high-risk HPV-positive samples had a sensitivity of 92% (95% confidence interval: 84-97) and a specificity of 61% (95% confidence interval: 54-69) for ≥CIN3. Applying p16/Ki-67 triage to only high-risk HPV-positive women with low-grade Pap cytology showed a similar sensitivity of 92% (95% confidence interval: 84-97), with a specificity for ≥CIN3 of 64% (95% confidence interval: 56-71). For high-risk HPV-positive women with low-grade and normal Pap cytology, triage with p16/Ki-67 showed a sensitivity of 96% (95% confidence interval: 89-99), and a specificity of 58% (95% confidence interval: 50-65). HPV16/18 genotyping combined with Pap cytology showed a sensitivity and specificity for ≥CIN3 similar to Pap cytology with an atypical cells of undetermined significance threshold. Because the quality of Pap cytology worldwide varies, and differences in sensitivity and specificity are limited between the three selected strategies, p16/Ki-67 triage of all high-risk HPV-positive samples would be the most reliable strategy in triage of high-risk HPV-positive women with an increased specificity and similar sensitivity compared with Pap cytology triage.
Asunto(s)
Inhibidor p16 de la Quinasa Dependiente de Ciclina/metabolismo , Papillomavirus Humano 16/aislamiento & purificación , Antígeno Ki-67/metabolismo , Infecciones por Papillomavirus/complicaciones , Displasia del Cuello del Útero/diagnóstico , Neoplasias del Cuello Uterino/diagnóstico , Adulto , Femenino , Humanos , Persona de Mediana Edad , Infecciones por Papillomavirus/metabolismo , Infecciones por Papillomavirus/patología , Sensibilidad y Especificidad , Triaje , Neoplasias del Cuello Uterino/metabolismo , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/virología , Displasia del Cuello del Útero/metabolismo , Displasia del Cuello del Útero/patología , Displasia del Cuello del Útero/virologíaRESUMEN
INTRODUCTION: High-risk human papillomavirus (hrHPV) testing is expected to replace cytology as primary screening method for cervical cancer screening in an increasing number of countries. The high sensitivity of hrHPV testing is combined with a limited specificity which makes triaging of hrHPV positive women necessary. As an ideal triage method does not yet exist, an optimal triage strategy for hrHPV positive women based on current knowledge should be obtained. The aim of this article is to present an overview of available options for triage of hrHPV positive women, with their strengths and limitations and possible future opportunities. AREAS COVERED: Current knowledge on morphological biomarkers, molecular biomarkers and combined triage strategies will be discussed to give an overview of the state-of-the-art on triaging hrHPV positive women. The literature search was limited to studies on triage strategies for hrHPV positive women. Expert commentary: Experience with morphology-based biomarkers makes these a valuable triage method. However, they lack the ability of differentiating productive from transforming infections. Molecular biomarkers are objective, highly reproducible, can be used in high throughput testing, and show promising results. With more extensive knowledge on these molecular markers, cervical cancer screening may transform to a full molecular screening in the future.
Asunto(s)
Detección Precoz del Cáncer/métodos , Infecciones por Papillomavirus/diagnóstico , Neoplasias del Cuello Uterino/diagnóstico , Biomarcadores/análisis , Femenino , Ensayos Analíticos de Alto Rendimiento/métodos , Humanos , Tamizaje Masivo/métodos , Infecciones por Papillomavirus/complicaciones , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Triaje/métodos , Neoplasias del Cuello Uterino/virologíaRESUMEN
Cytology alone, or combined with HPV16/18 genotyping, might be an acceptable method for triage in hrHPV-cervical cancer screening. Previously studied HPV-genotype based triage algorithms are based on cytology performed without knowledge of hrHPV status. The aim of this study was to explore the value of hrHPV genotyping combined with cytology as triage tool for hrHPV-positive women. 520 hrHPV-positive women were included from a randomised controlled self-sampling trial on screening non-attendees (PROHTECT-3B). Eighteen baseline triage strategies were evaluated for cytology and hrHPV genotyping (Roche Cobas 4800) on physician-sampled triage material. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), referral rate, and number of referrals needed to diagnose (NRND) were calculated for CIN2+ and CIN3+. A triage strategy was considered acceptable if the NPV for CIN3+ was ≥98%, combined with maintenance or improvement of sensitivity and an increase in specificity in reference to the comparator, being cytology with a threshold of atypical cells of undetermined significance (ASC-US). Three triage strategies met the criteria: HPV16+ and/or ≥LSIL; HPV16+ and/or ≥HSIL; (HPV16+ and/or HPV18+) and/or ≥HSIL. Combining HPV16+ and/or ≥HSIL yielded the highest specificity (74.9%, 95% CI 70.5-78.9), with a sensitivity (94.4%, 95% CI 89.0-97.7) similar to the comparator (93.5%, 95% CI 87.7-97.1), and a decrease in referral rate from 52.2% to 39.5%. In case of prior knowledge of hrHPV presence, triage by cytology testing can be improved by adjusting its threshold, and combining it with HPV16/18 genotyping. These strategies improve the referral rate and specificity for detecting CIN3+ lesions, while maintaining adequate sensitivity.
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Genotipo , Papillomaviridae/genética , Infecciones por Papillomavirus/epidemiología , Infecciones por Papillomavirus/virología , Triaje , Adulto , Anciano , Femenino , Humanos , Tamizaje Masivo , Persona de Mediana Edad , Países Bajos/epidemiología , Papillomaviridae/clasificación , Infecciones por Papillomavirus/diagnóstico , Sensibilidad y Especificidad , Triaje/métodos , Neoplasias del Cuello Uterino/diagnóstico , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/etiología , Neoplasias del Cuello Uterino/prevención & control , Frotis Vaginal , Displasia del Cuello del Útero/epidemiología , Displasia del Cuello del Útero/etiología , Displasia del Cuello del Útero/patologíaRESUMEN
OBJECTIVES: DNA methylation analysis of cancer-related genes is a promising tool for HPV-positive women to identify those with cervical (pre)cancer (CIN3+) in need of treatment. However, clinical performance of methylation markers can be influenced by the sample type utilized. We describe a multiplex quantitative methylation-specific PCR that targets FAM19A4 and mir124-2 loci, to detect CIN3+ using both HPV-positive lavage- and brush self-samples. METHODS: We determined methylation thresholds for clinical classification using HPV-positive training sets comprising lavage self-samples of 182 women (including 40 with CIN3+) and brush self-samples of 224 women (including 61 with CIN3+). Subsequently, independent HPV-positive validation sets of 389 lavage self-samples (including 78 with CIN3+), and 254 brush self-samples (including 72 with CIN3+) were tested using the preset thresholds. Furthermore, the clinical performance of combined methylation analysis and HPV16/18 genotyping was determined. RESULTS: Training set analysis revealed similar FAM19A4 and mir124-2 thresholds for both self-sample types to yield highest CIN3+ sensitivity at 70% specificity. Validation set analysis resulted in a CIN3+ sensitivity of 70.5% (95%CI: 60.4-80.6) at a specificity of 67.8% (95%CI: 62.7-73.0) for lavage self-samples, and a CIN3+ sensitivity of 69.4% (95%CI: 58.8-80.1) at a 76.4% (95%CI: 70.2-82.6) specificity for brush self-samples. In combination with HPV16/18 genotyping, CIN3+ sensitivity and specificity were 88.5% (95%CI: 81.4-95.6) and 46.0% (95%CI: 40.4-51.5) for lavage self-samples, and 84.7% (95%CI: 76.4-93.0) and 54.9% (95%CI: 47.7-62.2) for brush self-samples. CONCLUSIONS: FAM19A4/mir124-2 methylation analysis performs equally well in HPV-positive lavage- and brush self-samples to identify women with CIN3+. In combination with HPV16/18 genotyping, significantly higher CIN3+ sensitivities are obtained, at decreased specificity.
Asunto(s)
Citocinas/genética , Metilación de ADN , MicroARNs/genética , Infecciones por Papillomavirus/genética , Displasia del Cuello del Útero/genética , Neoplasias del Cuello Uterino/genética , Adulto , Femenino , Genotipo , Papillomavirus Humano 16/genética , Papillomavirus Humano 16/aislamiento & purificación , Papillomavirus Humano 18/genética , Papillomavirus Humano 18/aislamiento & purificación , Humanos , MicroARNs/metabolismo , Persona de Mediana Edad , Infecciones por Papillomavirus/metabolismo , Infecciones por Papillomavirus/patología , Infecciones por Papillomavirus/virología , Neoplasias del Cuello Uterino/metabolismo , Neoplasias del Cuello Uterino/virología , Frotis Vaginal/métodos , Displasia del Cuello del Útero/metabolismo , Displasia del Cuello del Útero/virologíaRESUMEN
OBJECTIVES: Triage of HPV screen-positive women is needed to identify those with underlying cervical intraepithelial neoplasia grade 2/3 or worse (CIN2/3+). Presently, cytology on a physician-taken cervical scrape is mostly accepted as triage test, but needs follow-up testing in order not to miss severe disease. Here, we evaluated the performance of combined cytology and bi-marker CADM1/MAL-methylation analysis as triage test on physician-taken cervical scrapes of HPV positive women. METHODS: In this post-hoc analysis, we used 364 left-over HPV positive cytology triage samples of participants of a randomized controlled trial (PROHTECT-3: n=46,001) performed in population-based cervical screening. Study endpoints were CIN2+ and CIN3+ detection. Cytology testing with and without methylation marker analysis was evaluated with regard to sensitivity, specificity, positive and negative predictive value, and referral rate. RESULTS: Bi-marker CADM1/MAL-methylation positivity increased proportionally with severity of underlying lesions. Overall, cytology and bi-marker CADM1/MAL-methylation analysis yielded similar performances with regard to CIN3+ detection, yet in combination a significantly higher sensitivity for CIN3+ (88.7%) was obtained at a specificity of 53.6% and a colposcopy referral rate of 53.6%. The combined strategy detected all six cervical cancers, whereas triage by cytology alone failed to detect two of them. CONCLUSIONS: Cytology and bi-marker CADM1/MAL-methylation analysis perform complementary for CIN2+/CIN3+ detection when used as triage tool on cervical scrapes of HPV positive women. This approach not only results in a higher CIN3+ sensitivity than cytology triage with an acceptable referral rate, but also seems to reduce the risk of missing cervical cancers and advanced high-grade lesions.
Asunto(s)
Moléculas de Adhesión Celular/genética , Metilación de ADN , Inmunoglobulinas/genética , Proteínas Proteolipídicas Asociadas a Mielina y Linfocito/genética , Infecciones por Papillomavirus/genética , Displasia del Cuello del Útero/genética , Neoplasias del Cuello Uterino/genética , Adulto , Alphapapillomavirus/aislamiento & purificación , Biomarcadores de Tumor/genética , Molécula 1 de Adhesión Celular , Femenino , Humanos , Persona de Mediana Edad , Infecciones por Papillomavirus/patología , Factores de Riesgo , Triaje/métodos , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/virología , Frotis Vaginal/métodos , Displasia del Cuello del Útero/patología , Displasia del Cuello del Útero/virologíaRESUMEN
We determined whether the participation rate for a brush-based cervicovaginal self-sampling device is noninferior to the participation rate for a lavage-based one for testing for hrHPV (high-risk human papillomavirus). Additionally, positivity rates for hrHPV, the detection rates for cervical intraepithelial neoplasia grades 2 and 3 or worse (CIN2+/3+), and user comfort were compared. A total of 35,477 non-responders of the regular cervical screening program aged 33-63 years were invited to participate. Eligible women (n = 30,130) were randomly assigned to receive either a brush-based or a lavage-based device, and a questionnaire for reporting user convenience. Self-sampling responders testing hrHPV-positive were invited for a physician-taken sample for cytology; triage-positive women were referred for colposcopy. A total of 5,218 women participated in the brush-based sampling group (34.6%) and 4809 women in the lavage-based group (31.9%), i.e. an absolute difference of 2.7% (95%CI 1.8-4.2). The hrHPV-positivity rates in the two groups were identical (8.3%, relative risk (RR) 0.99, 95%CI 0.87-1.13). The detection of CIN2+ and CIN3+ in the brush group (2.0% for CIN2+; 1.3% for CIN3+) was similar to that in the lavage group (1.9% for CIN2+; 1.0% for CIN3+) with a cumulative RR of 1.01, 95%CI 0.83-1.24 for CIN2+ and 1.25, 95%CI 0.92-1.70 for CIN3+. The two self-sampling devices performed similarly in user comfort. In conclusion, offering a brush-based device to non-responders is noninferior to offering a lavage-based device in terms of participation. The two self-sampling methods are equally effective in detecting hrHPV, CIN2+/CIN3+ and are both well accepted.
Asunto(s)
Cuello del Útero/virología , Papillomaviridae/aislamiento & purificación , Adulto , Detección Precoz del Cáncer , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Neoplasias del Cuello Uterino/virología , Displasia del Cuello del Útero/virologíaRESUMEN
OBJECTIVES: Methylation marker analysis using bi-marker panel MAL/miR-124-2 is a promising triage test for identifying cervical (pre)cancer in high-risk human papillomavirus (hrHPV) positive women. Bi-marker panel MAL/miR-124-2 can be applied directly on self-sampled cervico-vaginal material and its sensitivity is non-inferior to that of cytology, yet at the cost of more colposcopy referrals. Our objective was to increase specificity of MAL/miR-124-2 methylation analysis by varying the assay thresholds and adding HPV16/18 genotyping. METHODS: 1019 hrHPV-positive women were selected from a randomized controlled self-sampling trial (PROHTECT-3; 33-63 years, n=46,001) and nine triage strategies with methylation testing of MAL/miR-124-2 and HPV16/18 genotyping were evaluated. The methylation assay threshold was set at four different predefined levels which correspond with clinical specificities for end-point cervical intra-epithelial grade 3 or worse (CIN3+) of 50%, 60%, 70%, and 80%. RESULTS: The CIN3+ sensitivity of methylation analysis decreased (73.5 to 44.9%) while specificity increased (47.2 to 83.4%) when increasing the assay threshold. CIN3+ sensitivity and specificity of HPV16/18 genotyping were 68.0% and 65.6%, respectively. Combined methylation analysis at threshold-80 and HPV16/18 genotyping yielded similar CIN3+ sensitivity as that of methylation only at threshold-50 (77.6%) with an increased specificity (54.8%). CONCLUSIONS: Combined triage by MAL/miR-124-2 methylation analysis with threshold-80 and HPV16/18 genotyping reaches high CIN3+ sensitivity with increased specificity to identify women with cervical (pre)cancer among HPV self-sample positive women. The combined strategy is attractive as it is fully molecular and identifies women at the highest risk of cervical (pre)cancer because of strongly elevated methylation levels and/or HPV16/18 positivity.
Asunto(s)
Cuello del Útero/virología , Papillomavirus Humano 16/genética , Papillomavirus Humano 18/genética , Displasia del Cuello del Útero/patología , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/virología , Metilación de ADN , ADN Viral/metabolismo , Autoevaluación Diagnóstica , Femenino , Genotipo , Papillomavirus Humano 16/aislamiento & purificación , Papillomavirus Humano 18/aislamiento & purificación , Humanos , MicroARNs , Clasificación del Tumor , Sensibilidad y Especificidad , Manejo de Especímenes/métodos , Neoplasias del Cuello Uterino/diagnóstico , Displasia del Cuello del Útero/diagnóstico , Displasia del Cuello del Útero/virologíaRESUMEN
OBJECTIVES: High attendance rates in cervical screening are essential for effective cancer prevention. Offering HPV self-sampling to non-responders increases participation rates. The objectives of this study were to determine why non-responders do not attend regular screening, and why they do or do not participate when offered a self-sampling device. METHODS: A questionnaire study was conducted in the Netherlands from October 2011 to December 2012. A total of 35,477 non-responders were invited to participate in an HPV self-sampling study; 5347 women did opt out. Finally, 30,130 women received a questionnaire and self-sampling device. RESULTS: The analysis was based on 9484 returned questionnaires (31.5%) with a self-sample specimen, and 682 (2.3%) without. Among women who returned both, the main reason for non-attendance to cervical screening was that they forgot to schedule an appointment (3068; 32.3%). The most important reason to use the self-sampling device was the opportunity to take a sample in their own time-setting (4763; 50.2%). A total of 30.9% of the women who did not use the self-sampling device preferred after all to have a cervical smear taken instead. CONCLUSIONS: Organisational barriers are the main reason for non-attendance in regular cervical screening. Important reasons for non-responders to the regular screening to use a self-sampling device are convenience and self-control.
Asunto(s)
Prueba de Papanicolaou/psicología , Infecciones por Papillomavirus/diagnóstico , Aceptación de la Atención de Salud/psicología , Frotis Vaginal/psicología , Salud de la Mujer , Adulto , Distribución por Edad , Detección Precoz del Cáncer/métodos , Femenino , Humanos , Persona de Mediana Edad , Países Bajos , Prueba de Papanicolaou/métodos , Prueba de Papanicolaou/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Prioridad del Paciente/psicología , Prioridad del Paciente/estadística & datos numéricos , Autocuidado/métodos , Autocuidado/psicología , Autocuidado/estadística & datos numéricos , Manejo de Especímenes/métodos , Encuestas y Cuestionarios , Factores de Tiempo , Frotis Vaginal/métodos , Frotis Vaginal/estadística & datos numéricosRESUMEN
BACKGROUND: Cytology is a widely used method of triaging women who test positive for human papillomavirus (HPV). However, self-sampled specimens, which can substantially increase participation in screening programmes, are not suitable for accurate cytological assessment. We investigated whether direct DNA methylation-based molecular triage on self-sampled cervicovaginal specimens was non-inferior to cytology triage on additional physician-collected cervical samples in the detection of cervical intraepithelial neoplasia grade 2 (CIN2) or worse in women who did not attend cervical screening programmes. METHODS: In this randomised controlled non-inferiority trial, we invited women (aged 33-63 years) registered as non-attendees of cervical screening in the Netherlands in 2007 to submit a self-collected cervicovaginal sample for HPV testing. Using a computer-generated sequence, we randomly allocated women who tested positive for high-risk hrHPV on a self-sample to either triage by cytology on an additional physician-taken smear or direct triage on the self-sample by methylation analysis of MAL and miR-124-2 genes (1:1; stratified by age and region, with block sizes by age group). Triage-positive women in either group were referred for colposcopy. The primary endpoint was detection of CIN2 or worse, analysed by intention to treat. The non-inferiority margin was 0·80. This study is registered in the Primary Trial Register of the Netherlands, number NTR6026. FINDINGS: We invited 46,001 women to participate, 12,819 of whom returned self-sampled material; 1038 samples tested positive for high-risk HPV. Between Nov 1, 2010, and Dec 31, 2011, after exclusion of women who were ineligible, we enrolled and randomly allocated 515 women to methylation triage and 509 to cytology triage. The detection of CIN2 or worse with methylation triage was non-inferior to that with cytology triage (90 [17%] of 515 women vs 75 [15%] of 509 women; relative risk 1·19, 95% CI 0·90-1·57). Referral for colposcopy was more common in the molecular group (284 [55%] women) than in the cytology group (149 [29%] women; p<0·0001). Mean time to CIN2 or worse diagnosis was shorter in the molecular triage group (96 days, range 44-101) than in the cytology triage group (158 days, 71-222; p=0·00084). INTERPRETATION: DNA methylation analysis of MAL and miR-124-2 genes on HPV-test-positive self-samples is non-inferior to cytology triage in the detection of CIN2 or worse, opening the way to full molecular screening. FUNDING: Midden-West and Oost Screening Organisations and Stichting Achmea Gezondheidszorg.
Asunto(s)
Metilación de ADN , Papillomaviridae/aislamiento & purificación , Triaje , Displasia del Cuello del Útero/diagnóstico , Neoplasias del Cuello Uterino/diagnóstico , Frotis Vaginal/métodos , Adulto , Colposcopía , Femenino , Humanos , MicroARNs/genética , Persona de Mediana Edad , Proteínas Proteolipídicas Asociadas a Mielina y Linfocito/genética , Manejo de EspecímenesRESUMEN
Cervical screening programs for detecting cancer and precancer have dramatically reduced the incidence and mortality rates of cervical cancer since the 1960s. The efficacy of the screening programs depends on participation and the accuracy of the screening tests. Unfortunately, the participation rates are suboptimal; more than half the women with cervical cancer have not or have only sporadically been screened. Increasing participation is the best way of maximizing the program's benefit. Furthermore, cytology screening lacks high sensitivity for high-grade cervical intraepithelial neoplasia (≥CIN2). High-risk human papillomavirus (hrHPV) screening is more sensitive in the detection of cervical intraepithelial neoplasia than cytology screening, but less specific, so that additional triage testing is still mandatory. The aim of this article is to reflect on the efficacy of current cervical cancer screening and on promising future screening strategies with primary hrHPV testing and additional triage strategies for hrHPV-positive screening results.
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Tamizaje Masivo/métodos , Displasia del Cuello del Útero/diagnóstico , Neoplasias del Cuello Uterino/diagnóstico , Detección Precoz del Cáncer/métodos , Femenino , Humanos , Infecciones por Papillomavirus/complicaciones , Infecciones por Papillomavirus/diagnóstico , Aceptación de la Atención de Salud , Lesiones Precancerosas/diagnóstico , Lesiones Precancerosas/patología , Sensibilidad y Especificidad , Neoplasias del Cuello Uterino/complicaciones , Neoplasias del Cuello Uterino/patología , Displasia del Cuello del Útero/patologíaRESUMEN
OBJECTIVE: To determine the reasons for women's anxiety and psychological stress before and during colposcopy, in order to define strategies to decrease their stress. METHODS: Qualitative study with 15 women participating in four focus groups between April 2011 and April 2012. All participants were diagnosed with a cervical cytological abnormality and attended a gynecologist's clinic to undergo colposcopy. The focus group interview was audio-taped and transcribed verbatim. The data were analyzed using qualitative content analysis to identify themes. RESULTS: Psychological stress before colposcopy was seen as being caused by unsatisfactory explanation of abnormal cervical smears and the colposcopy procedure itself. Additionally, a fear of cancer, pain and discomfort, embarrassment, waiting time in the hospital, and a longer interval between referral and the actual colposcopy appointment increased psychological stress and anxiety. Women indicated that more detailed and practical information about the cervical smear result and the colposcopy procedure may reduce stress and anxiety. CONCLUSION: In order to minimize the adverse psychological consequences of an abnormal cervical smear and colposcopy, timely, practical and detailed information needs to be provided to the women, and waiting and access times need to be as short as possible. These measures may reduce the psychological stress and anxiety, however some stress and anxiety will always remain, and may even be desirable in order to ensure proper follow-up of abnormal cervical smears.
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Ansiedad/psicología , Colposcopía/psicología , Estrés Psicológico/psicología , Adulto , Miedo/psicología , Femenino , Grupos Focales , Conocimientos, Actitudes y Práctica en Salud , Humanos , Persona de Mediana Edad , Investigación Cualitativa , Encuestas y Cuestionarios , Factores de Tiempo , Neoplasias del Cuello Uterino/diagnóstico , Neoplasias del Cuello Uterino/psicología , Frotis Vaginal/psicologíaRESUMEN
OBJECTIVE: To determine the overtreatment rate at colposcopy in women who underwent a see-and-treat protocol. METHODS: We identified 3,192 patients (mean age 36 years, standard deviation 8.7) who underwent a see-and-treat protocol in Radboud University Nijmegen Medical Center between January 1981 and December 2010. Overtreatment, defined as cervical intraepithelial neoplasia 1 or less at final histopathology analysis, was investigated in relation to the age of the women, time of referral, cervical smear result, colposcopic impression, and histopathology result. RESULTS: A total of 579 women (18.1%, 95% confidence interval [CI] 16.7-19.5) were overtreated. The lowest overtreatment rate (4.5%, 95% CI 3.5-5.5) was seen in women with both a high-grade cervical smear result and a high-grade colposcopic impression. Women aged younger than 40 years were less likely to be overtreated (13.1%, 95% CI 11.7-14.5) than women aged 40-49 years (24.2% 95% CI 21.2-27.4, number needed to harm nine) and aged 50 years and older (42.2%, 95% CI 36.5-47.7, number needed to harm three). CONCLUSIONS: The overtreatment rate is low for patients with both a high-grade smear result and a high-grade colposcopic impression, justifying a see-and-treat approach for these patients. In women with either a high-grade smear result or a high-grade impression on colposcopy, a see-and-treat approach may still be preferable but has higher overtreatment rates. Given the side effects of cervical surgery on pregnancy outcome, young women, in particular those who have either a low-grade smear result or low-grade impression on colposcopy, are better served by a two-step approach. In older women, a see-and-treat policy may be preferable.
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Colposcopía/estadística & datos numéricos , Procedimientos Innecesarios/estadística & datos numéricos , Displasia del Cuello del Útero/cirugía , Neoplasias del Cuello Uterino/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Persona de Mediana Edad , Neoplasias del Cuello Uterino/diagnóstico , Frotis Vaginal , Adulto Joven , Displasia del Cuello del Útero/diagnósticoRESUMEN
BACKGROUND: Attendance rates of cervical screening programs can be increased by offering HPV self-sampling to non-attendees. Acceptability, DNA yield, lavage volumes and choice of hrHPV test can influence effectiveness of the self-sampling procedures and could therefore play a role in recruiting non-attendees. To increase user-friendliness, a frequently used lavage sampler was modified. In this study, we compared this second generation lavage device with the first generation device within similar birth cohorts. METHODS: Within a large self-sampling cohort-study among non-responders of the Dutch cervical screening program, a subset of 2,644 women received a second generation self-sampling lavage device, while 11,977 women, matched for age and ZIP-code, received the first generation model. The second generation device was different in shape, color, lavage volume, and packaging, in comparison to its first generation model. The Cochran's test was used to compare both devices for hrHPV positivity rate and response rate. To correct for possible heterogeneity between age and ZIP codes in both groups the Breslow-Day test of homogeneity was used. A T-test was utilized to compare DNA yields of the obtained material in both groups. RESULTS: Median DNA yields were 90.4 µg/ml (95% CI 83.2-97.5) and 91.1 µg/ml (95% CI 77.8-104.4, p= 0.726) and hrHPV positivity rates were 8.2% and 6.9% (p= 0.419) per sample self-collected by the second - and the first generation of the device (p= 0.726), respectively. In addition, response rates were comparable for the two models (35.4% versus 34.4%, p= 0.654). CONCLUSIONS: Replacing the first generation self-sampling device by an ergonomically improved, second generation device resulted in equal DNA yields, comparable hrHPV positivity rates and similar response rates. Therefore, it can be concluded that the clinical performance of the first and second generation models are similar. Moreover, participation of non-attendees in cervical cancer screening is probably not predominantly determined by the type of self-collection device.
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Pruebas de ADN del Papillomavirus Humano/instrumentación , Infecciones por Papillomavirus/diagnóstico , Ducha Vaginal/instrumentación , Frotis Vaginal/instrumentación , Adulto , Estudios de Cohortes , Diseño de Equipo , Femenino , Humanos , Persona de Mediana Edad , Países Bajos , AutoadministraciónRESUMEN
Primary screening using high-risk human papillomavirus (hrHPV) detection has been suggested as a way of improving cervical cancer prevention. Women currently not attending screening (nonresponders) are more likely to participate when given the opportunity of self-sampling for hrHPV testing. The Evalyn Brush is a new cervicovaginal self-sampling device, developed specifically to meet women's demands, which is user-friendly and easy to use. The aims of this study were to investigate agreement of hrHPV detection by two PCR methods between the Evalyn Brush and physician-obtained samples and to study women's acceptance of this self-sampling device. Each of 134 women visiting the gynecology outpatient clinic collected a self-obtained sample (self-sample) and completed a questionnaire. The brush was stored dry. After self-sampling, a trained physician obtained a conventional cervical cytology specimen in ThinPrep medium. HrHPV detection was performed using the SPF(10)-DEIA-LiPA(25) and GP5+/6+-LQ-test. The overall agreement for hrHPV detection using SPF(10)-DEIA-LiPA(25) between the self-sample and the physician-taken sample was 85.8% (kappa value, 0.715; 95% confidence interval [CI], 0.597 to 0.843; P = 1.000). The overall agreement for hrHPV detection using GP5+/6+-LQ between the self-sample and the physician-taken sample was 86.6% (kappa value, 0.725; 95% CI, 0.607 to 0.843; P = 0.815). Ninety-eight percent of the women rated their experience as good to excellent. Moreover, 95% of women preferred self-sampling to physician sampling. Self-sampling using the dry Evalyn Brush system is as good as a physician-taken sample for hrHPV detection and is highly acceptable to women. To validate this self-sampling device for clinical use, a large screening cohort should be studied.
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Técnicas de Laboratorio Clínico/métodos , Detección Precoz del Cáncer/métodos , Papillomaviridae/aislamiento & purificación , Infecciones por Papillomavirus/diagnóstico , Autoadministración/métodos , Manejo de Especímenes/métodos , Virología/métodos , Adulto , Anciano , Cuello del Útero/virología , Femenino , Humanos , Persona de Mediana Edad , Infecciones por Papillomavirus/virología , Aceptación de la Atención de Salud , Reacción en Cadena de la Polimerasa/métodos , Adulto JovenRESUMEN
Flaring of the costal arch may be part of the pectus excavatum deformity. This aspect will in rare cases be even worsen after the Nuss repair. This remaining deformity can be treated with a minimal subperichondral partial resection of the costal arch cartilage. In 5 patients, this additional technique regained good to excellent results.
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Cartílago/cirugía , Tórax en Embudo/cirugía , Enfermedades Musculoesqueléticas/cirugía , Procedimientos de Cirugía Plástica/efectos adversos , Costillas/cirugía , Adolescente , Femenino , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Enfermedades Musculoesqueléticas/etiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: The Nuss procedure was introduced at our center in 1999. The operation was mainly performed for cosmesis. Little information is available regarding the influence of this operation on lung function. METHODS: The aim of this study, a prospective analysis, was to analyze the effect of the Nuss procedure on lung function variables. Between 1999 and 2007 a total of 203 patients with pectus excavatum were treated with the Nuss procedure, of whom 145 (104 male, 41 female) were located at Emma Children's Hospital. In the latter subset of consecutive patients, static lung function variables [total lung capacity (TLC), functional residual capacity (FRC), vital capacity (VC)] and dynamic lung function variables [forced expired volume in 1 s (FEV(1)), maximum expiratory flow (MEF(50))] were performed using spirometry and body box measurements at four time points: prior to operation (T0), 6 months after the Nuss procedure (T1, n = 111), prior to removal of the Nuss bar (T2, n = 74), and 6 months after removal (T3, n = 53). All values were expressed as a percent of normal values for sex, age, and height. Results were compared with a paired-samples t-test, with the level of significance at p = 0.05. RESULTS: At 6 months after bar insertion the TLC, FRC, VC, FEV(1), and MEF(50) showed a significant increase; and prior to bar removal the FRC and MEF(50) showed significantly increased values. At 6 months after Nuss bar removal, none of the lung function variables showed any significant change compared to the preoperative values. CONCLUSION: After the Nuss procedure for pectus excavatum, there was no improvement of pulmonary function, but neither was the patient's pulmonary function harmed by resolving a largely cosmetic problem.