Human Papillomavirus (HPV) vaccination coverage among French adolescents: A claims data study.

BACKGROUND: The French cancer control strategy 2021-2030 aims to achieve 80 % human papillomavirus (HPV) vaccination coverage. Since 2021, HPV vaccination is also recommended for boys aged 11-14 years, with a catch-up vaccination recommended for unvaccinated adolescents aged ≤19 years. The PAPILLON study used claims data to monitor the evolution of HPV Vaccination Coverage Rate (VCR) in the French population. METHODS: The annual HPV VCR was described from 2017 to 2022. Partial vaccination was defined as the dispensing of at least one dose of HPV vaccination. Full scheme vaccination was defined according to the current French recommendations as two or three doses of HPV vaccine over an 18-month period. Annual HPV vaccine initiation rates were estimated on 11-14 and 15-19-year-olds adolescents. Cumulative VCR were estimated on adolescents aged between 11 and 19 years at the time of first vaccination. RESULTS: Overall, 1,773,900 females and 592,167 males initiated HPV vaccination between 2017 and 2022. Initiations occurred between 11 and 14 years for 67.3 % of females and 62.4 % of males with a median time between the first two doses of 195 days and 190 days, respectively. In girls, the cumulative vaccination rate for the partial scheme vaccination at 15 y.o. increased from 28.1 % in 2017 to 50.9 % in 2022. Similarly, the cumulative vaccination rate for the full scheme vaccination at 16 y.o. increased from 15.5 % in 2017 to 33.8 % in 2022. In 2022, the initiation rates for males were 12.6 % at age 14 and 1.9 % at age 19. CONCLUSIONS: HPV vaccination coverage increased between 2017 and 2022 among girls targeted by the recommendation but remains insufficient. The results of this study show a tentative but promising start to vaccination in boys. This study will monitor the effects of actions taken to improve vaccination, including the extension of vaccination competencies to community pharmacists since end of 2022.

[Outpatient laparoscopic hysterectomy in France: A monocentric randomized trial]. / Hystérectomie cœlioscopique ambulatoire en France : étude randomisée unicentrique.

OBJECTIVE: To demonstrate the feasibility of outpatient laparoscopic hysterectomy using the assessment of post-operative quality of life. METHODS: A prospective randomized single-center trial was performed in France between 2013 and 2016. A total of 42 patients needed laparoscopic hysterectomy was included. Postoperative quality of life was assessed using the standardized Euroquol questionnaire. Patients filled the score before the operation and then on the 3rd and 30th postoperative day. Secondary outcomes were assessment of postoperative pain, overall quality of life, analgesic use, and anxiety. The patients were randomized into two groups, group A with a conventional hospital stay of 2 to 3 days and group B with a short stay and a discharge the day after the intervention. RESULTS: Twenty-one patients were randomized to group A as well as group B. We did not find any significant differences between the two groups in our study either on our primary outcome or in the seconds ones. On day 3, the average of Euroquol score was 0.68 for group A against 0.50 for group B (P=0.05). Likewise, the scores for postoperative pain were similar with 70.6 in group A and 61.8 in group B (P=0.21). The trend was the same for quality of life score or anxiety. CONCLUSION: Our study shows the possibility and the safety of outpatient laparoscopic hysterectomy.

[Interest of a geostatistical approach to analyze the geographical disparities in human papillomavirus vaccine coverage in France]. / Intérêt d'une approche géostatistique pour analyser les disparités géographiques de la couverture vaccinale contre les papillomavirus humains en France.

BACKGROUND: The use of geostatistical methods remains rare in health studies. In order to assess the usefulness of the geostatistical approach in epidemiology, we chose to apply these methods to the vaccination coverage rate (VCR) against human papillomavirus (HPV) in France. Indeed, HPV vaccine coverage remains low in France and geographical disparities are sizable. The objective of this study was to identify the socioecological factors that may explain these geographical variations. METHODS: Sociological, economic and behavioral data for 2016 have been gathered (demographics and public health database, web and social networks) and were correlated with the HPV VCR vaccine coverage over the French territory. Homogeneous geographical areas defined by strong correlations for groups of variables were selected. In each homogeneous area, principal component analysis was performed and a geostatistical approach provided an estimate predicting vaccine coverage at a given scale. RESULTS: HPV VCR spatial variations in France cannot be fully explained by a single model. In urban areas, a low rate of HPV VCR is preferentially associated with unfavorable socioeconomic factors (poverty, unemployment, immigration). In rural areas, HPV VCR is preferentially associated with sociocultural factors (socio-professional categories, education level, interest in alternative medicines the anti-vaccine movement). Two secondary geographical areas were defined: the Île-de-France region and 12 departments in northeastern France. In the Île-de-France region, the association with the economic factors one again appears as in urban areas in general. The northeasteran departments represent a particular case insofar as HPV VCR is relatively high, notwithstanding economic poverty indicators. CONCLUSION: Geostatistical modeling successfully identifies new potential explanations for HPV VCR geographical disparities in France. These results could help to adapt or develop future vaccination programs in specific areas by taking into account the sociological, economic and behavioral characteristics of their populations.

[Use of HPV virologic test for atypical glandular cells in Alsace between 2014 and 2016]. / Recours au test virologique HPV dans la prise en charge des atypies glandulaires en Alsace entre 2014 et 2016.

OBJECTIVES: The new recommendations by the National Institute of Cancer (January 2017) recommend the use of a complementary human papillomavirus (HPV) virologic test during the diagnosis of atypical glandular cells in pap smear. The aim of this study was the performance analysis of the HPV virologic test for the detection of significant histological cervical abnormalities (CIN2 or more) in case of atypical glandular cells before the new recommendations were published. METHODS: We performed a descriptive and retrospective cohort study in Alsace between January 2014 and December 2016. We have included, from the EVE-association database, the patients with atypical glandular cells in pap smear. RESULTS: In total, 1074 patients had a pap smear with atypical glandular cells ; 0.18% of total pap smears. This study included 152 patients who had a HPV test. We observed 6 cases of CIN2 (3.9%) and 12 cases of CIN3 (7.9%). No in situ adenocarcinoma nor invasive carcinoma were detected. The sensitivity of the HPV test was 88.9% (95% CI: [0.65; 0.99]), the specificity was 65.9% (95% CI: [0.55; 0.76]), the positive predictive value was 34% (95% CI: [0.21; 0.49]) and the negative predictive value was 96.8% (95% CI: [0.89; 0.99]). CONCLUSION: The detection of HPV in atypical glandular cells seems to be powerful with an excellent negative predictive value but, because of moderate sensitivity and due to the risk of histologic lesion progression, the current recommendations should to be applied with care.

Laparoscopic pelvic lymphadenectomy in patients with intermediate-risk endometrial cancer: Is it worth it?

OBJECTIVE: The main aim of this study is to evaluate operative and postoperative morbidity of laparoscopic pelvic lymphadenectomy as well as its potential impact on the postoperative management in patients with an intermediate-risk of endometrial cancer. METHODS: We did a retrospective study between January 2009 and December 2013. We included all patients operated by laparoscopy for endometrial cancer presumed to have an intermediate-risk of recurrence. Pelvic lymphadenectomy in this group of patients was performed at the discretion of operating surgeons. Patients were consequently divided into two groups according to whether or not pelvic lymphadenectomy was performed. We made a comparative analysis between these two groups. RESULTS: Overall, 116 patients were managed for endometrial cancer presumed to be intermediate-risk. Among these, 93 received treatment with laparoscopy and were included in the study. Patients' characteristics did not differ between the two groups. The mean duration of surgery was significantly longer when pelvic lymphadenectomy was performed. The average number of retrieved lymph nodes was 13 and we had seven patients with positive lymph nodes (10%). CONCLUSION: Pelvic lymphadenectomy allows a better postoperative classification for some patients without more complication.

[Health-related quality of life in patients treated for ovarian cancer: tools and issues]. / Étude de la qualité de vie dans les néoplasies ovariennes : outils et enjeux.

Health-related quality of life (QoL) in patients treated for ovarian cancer is directly and heavily impacted by the natural history of cancer, its evolution and its therapeutic modalities. The evaluation and consideration of various parameters of QoL seems to be a major issue. Indeed, on the one hand, it is essential to take into account the opinion of patients in the choice of therapeutic strategies for this cancer with a poor prognosis and, on the other hand, more and more studies show that QoL is an independent prognostic factor in ovarian cancer. Improvement in this case, in addition to being an endpoint by itself, would potentially improve the overall survival of patients. To date there are several tools to assess QOL of patients with ovarian cancer. The 2 questionnaires most commonly used are: FACT-O and the EORTC QLQ-OV28. The aim of our study was to evaluate from a review of the literature, the reciprocal effects of ovarian cancer on QoL and QoL on ovarian cancer survival, as well as specificities of each of the 2 questionnaires most commonly used in assessing the QoL.

[Reliability of endocervical curettage after conservative treatment of intraepithelial neoplasia of the cervix]. / Fiabilité du curetage endocervical après traitement conservateur des néoplasies intraépithéliales du col utérin.

OBJECTIVE: To evaluate the reliability of endocervical curettage (ECC) in patients previously treated for CIN. PATIENTS AND METHODS: Retrospective analysis of data from 85 patients between January 1985 and December 2011 who received an ECC during monitoring after treatment of CIN. The reliability of the ECC was evaluated by comparison with the final histological analysis of the surgical specimen or the data for subsequent cyto-colpo-histological follow-up. RESULTS: Patients were referred to colposcopy either within the immediate post-treatment monitoring (n=42), meanly 9.7±5.3 months after treatment, or if cytological abnormalities were detected during long-term monitoring, meanly 78.6±52.4 months after treatment. Colposcopy was unsatisfactory in 75.3% of patients and normal colposcopic findings were found in 80% of patients. A perfect agreement between the ECC and the endocervical final diagnosis was noted in 68 patients (80%). For the diagnosis of severe cervical lesions (CIN 2+) ECC had a sensitivity of 86.2% (68.3-96.1), a specificity of 94.6% (85.1-98.9) and positive and negative predictive values of 61.4% (47.6-74.0) and 93% (83.0-98.1), respectively. CONCLUSION: The high sensitivity and negative predictive value of ECC for the diagnosis of severe post-therapeutic endocervical lesions avoid iterative treatment without increasing the risk of progression of a lesion to cancer.

[Prevention of obstetrical complications following LEEP, is it possible?]. / Prévention des conséquences obstétricales des conisations à l'anse diathermique, est-ce possible ?

Recent epidemiological data suggest an increase of the incidence and prevalence of CIN as well as a decrease of the mean age of the patients presenting these lesions. Large loop electrosurgical procedure (LEEP) is the most commonly used treatment method. According to recent studies LEEP provides a 1.4 to 7.0 fold increase of preterm delivery. Cervical cerclage does not show efficiency in reducing this risk, even if cervical shortening is measured by transvaginal ultrasound. Considering histological severity of lesions and the age of patients, number of currently conducted conizations in France could be avoided and so their obstetrical consequences prevented, just because no treatment is necessary or could be done by ablative procedures.

[Pertinence of the preoperative exploration in the evaluation of the risk of lymph node metastasis in endometrial cancer]. / Pertinence du bilan préoperatoire dans l'évaluation du risque de métastases ganglionnaires d'un cancer endométrial.

PURPOSE: To assess the relevance of MRI, endometrial biopsy and curettage in the diagnosis of endometrial cancer at high risk of lymph node metastasis. PATIENTS AND METHODS: A retrospective study on continuous series of patients treated for endometrial cancer limited to the uterus between 2004 and 2008, results of preoperative evaluation of tumor stage using MRI, histological type and grade by endometrial curettage and biopsies were compared to final histological examination. RESULTS: One hundred and sixty-nine patients were included in the study. Ninety (53.3%) had MRI, 112 (66.2%) curettage and 61 (36.6%) endometrial biopsy using Pipelle de Cornier. Sensibility (SN), specificity (SP), positive (PPV) and negative predictive values (NPV) of MRI, in the diagnosis of endometrial cancer at high risk of lymph nodes metastases were of 65.6%, 87.2%, 77.7%, 79.2%. For EB and curettage SN, SP, PPV and NPV were of 42.9%, 96.9%, 85%, 79.5%; 80.6%, 98.3%, 96.2% and 90.6% respectively. 37.8% of cancers diagnosed to be at low risk of lymph node metastasis were at high risk in definitive histologic examination. DISCUSSION AND CONCLUSION: Preoperative evaluation by MRI, endometrial curettage and biopsy has good diagnostic value in the identification of endometrial cancer susceptible to benefit from lymphadenectomy. Underestimation, however, is encountered in approximately one third of cases.

[Obstetric outcomes following LOOP-excision]. / Conséquences obstétricales des conisations à l'anse diathermique et facteurs aggravants.

The obstetrical consequences of conisation for cervical intraepithelial neoplasia (CIN) should be considered since patients affected by these lesions are actually younger and most often desire further pregnancies. The loop electrosurgical excision procedure (LEEP), which is currently mostly used, achieves cure rate varying according to the authors between 80 and 95%. However, the most recent data show an increase of obstetrical morbidity, especially prematurity, after LEEP excision. As the frequency and severity of prematurity is correlated to the size and depth of the LEEP, we should minimize as much as possible the resection for these young patients.

A prospective randomized study of two reminding strategies: telephone versus mail in the screening of cervical cancer in women who did not initially respond.

OBJECTIVE: To compare the efficacy and cost-effectiveness of two reminding strategies addressed to women who did not respond to a first invitation to undergo cervical cancer screening. STUDY DESIGN: A randomized study was carried out by a programme created in Alsace to organize cervical cancer screening. In total, 10,662 women who did not have a smear test 1 year after a first notice was sent, were randomly allocated to receive either a new letter with a reply coupon or a telephone call. The uptake of screening was measured using routine data. Efficacy and direct costs of the two methods were compared. RESULTS: Uptake at 8 months was 6.3% [95% confidence interval (CI) 5.6-7.0%] for telephone calls and 5.8% (95% CI 5.2-6.4%) for letters. The difference was not significant. More information was collected through telephone calls than by letters, but with less reliability. Furthermore, telephone calls were more costly. CONCLUSIONS: We found that in our region, a mail reminder was as effective as, and less expensive than, a telephone call; moreover, it was applicable to the whole population, including patients without a telephone.

[Is early cervical cancer screening justified?]. / Le dépistage précoce du cancer du col est-il justifié?

Pap smear screening of women under 25 years old remains controversial. No randomized study exists on this topic. The perception of individual benefit often prevails, although there is no proof of effectiveness and no demonstrated risk-benefit ratio. A review of published studies - taking into account epidemiological data, effectiveness of screening of young women, adverse medical outcomes and costs - suggests that there are more arguments against screening before 25 than in favour of it.

[Cervical screening: toward a new paradigm?]. / Un nouveau paradigme pour le dépistage du cancer du col utérin?

OBJECTIVES: Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening. MATERIAL AND METHODS: The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France. RESULTS: The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary. CONCLUSION: The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

European guidelines for clinical management of abnormal cervical cytology, part 2.

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1.

The current paper presents the first part of Chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to manage women with abnormal cervical cytology. Throughout this article the Bethesda system is used for cervical cytology terminology, as the European guidelines have recommended that all systems should at least be translated into that terminology while cervical intraepithelial neoplasia (CIN) is used for histological biopsies (Cytopathology 2007; 18:213-9). A woman with a high-grade cytological lesion, a repeated low-grade lesion or with an equivocal cytology result and a positive human papillomavirus (HPV) test should be referred for colposcopy. The role of the colposcopist is to identify the source of the abnormal cells and to make an informed decision as to whether or not any treatment is required. If a patient requires treatment the colposcopist will decide which is the most appropriate method of treatment for each individual woman. The colposcopist should also organize appropriate follow-up for each woman seen. Reflex testing for high-risk HPV types of women with atypical squamous cells (ASC) of undetermined significance with referral for colposcopy of women who test positive is a first option. Repeat cytology is a second possibility. Direct referral to a gynaecologist should be restricted to special circumstances. Follow-up of low-grade squamous intraepithelial lesion is more difficult because currently there is no evidence to support any method of management as being optimal; repeat cytology and colposcopy are options, but HPV testing is not sufficiently selective, unless for older women. Women with high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC-H) should be referred without triage. Women with glandular lesions require particular attention. In a subsequent issue of Cytopathology, the second part of Chapter 6 will be presented, with recommendations for management and treatment of histologically confirmed intraepithelial neoplasia and guidance for follow-up of special cases such as women who are pregnant, postmenopausal or immunocompromised.

European guidelines for quality assurance in cervical cancer screening: recommendations for collecting samples for conventional and liquid-based cytology.

The current paper presents an annex in the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to make a satisfactory conventional Pap smear or a liquid-based cytology (LBC) sample. Practitioners taking samples for cytology should first explain to the woman the purpose, the procedure and how the result will be communicated. Three sampling methods are considered as acceptable for preparing conventional Pap smears: (i) the cervical broom; (ii) the combination of a spatula and an endocervical brush; and (iii) the extended tip spatula. Smear takers should take care to sample the entire circumference of the transformation zone, to quickly spread the cellular material over a glass slide, and to fix the preparation within a few seconds to avoid drying artefacts. According to local guidelines, one of these three methods may be preferred. Sampling with a cotton tip applicator is inappropriate. Similar procedures should be followed for sampling cells for LBC, but only plastic devices may be used. The collected cells should be quickly transferred into a vial with fixative liquid according to the instructions of the manufacturer of the LBC system. Subsequently, the slide or vial and the completed request form are sent to the laboratory for cytological interpretation.