A questionnaire study on disparity of cervical cancer prevention programs in Asia-Oceania.

BACKGROUND: Despite the introduction of cervical cancer screening and human papillomavirus (HPV) vaccines, the utilization pattern was not standardized. The aim of this study was to elicit the current prevention care in Asia-Oceania. METHODS: An online questionnaire was circulated to different countries/cities in Asia-Oceania. The primary objective was to evaluate the coverage of HPV vaccination and cervical screening programs. The secondary objectives were to study the structures of these programs. Five case scenarios were set to understand how the respondents manage the abnormal screening results. RESULTS: Fourteen respondents from 10 countries/cities had participated. Cervical cancer ranked the first in Myanmar and Nepal. About 10%-15% did not have national vaccination or screening program. The estimated coverage rate for vaccination and screening varied from less than 1% to 70%, which the coverage ran in parallel with the incidence and mortality rates of cervical cancer. All regions approved HPV vaccines, although only four provided free or subsidized programs for nonavalent vaccine. Cervical cytology remained the most common screening tool, and 20%-30% relied heavily on visual inspection using acetic acid. The screening age groups varied in different regions. From the case scenarios, it was noted that some respondents tended to offer more frequent screening tests or colposcopy than recommended by international guidelines. CONCLUSION: This study revealed discrepancy in the practice of cervical cancer prevention in Asia-Oceania especially access to HPV vaccines. There is an urgent need for a global collaboration to eliminate cervical cancer by public education, reforming services, and medical training.

COVID-19 and gynecological cancers: Asia and Oceania Federation of Obstetrics and Gynecology oncology committee opinion.

Since the outbreak of COVID-19, there have already been over 26 million people being infected and it is expected that the pandemic will not end in near future. Not only the daily activities and lifestyles of individuals have been affected, the medical practice has also been modified to cope with this emergency catastrophe. In particular, the cancer services have faced an unprecedented challenge. While the services may have been cut by the national authorities or hospitals due to shortage of manpower and resources, the medical need of cancer patients has increased. Cancer patients who are receiving active treatment may develop various kinds of complications especially immunosuppression from chemotherapy, and they and their carers will need additional protection against COVID-19. Besides, there is also evidence that cancer patients are more prone to deteriorate from COVID-19 if they contract the viral infection. Therefore, it is crucial to establish guidelines so that healthcare providers can triage their resources to take care of the most needed patients, reduce less important hospitalization and visit, and to avoid potential complications from treatment. The Asia and Oceania Federation of Obstetrics and Gynecology (AOFOG) hereby issued this opinion statement on the management of gynecological cancer patients during the COVID-19.

PD-L1 Expressing Recurrent Clear Cell Carcinoma of the Vulva with Durable Partial Response to Pembrolizumab: A Case Report.

BACKGROUND: The optimal treatment and molecular landscape of recurrent clear cell carcinoma of the vulva (VCCC) are unknown. No reported data exist regarding the efficacy of anti-programmed death 1 (PD-1) immune checkpoint inhibition in VCCC. We report on a patient with chemotherapy-refractory recurrent VCCC, who was found to have high tumor programmed death-ligand 1 (PD-L1) combined positive score (CPS), and subsequently experienced a durable partial response (PR), after treatment with off-label fifth-line pembrolizumab. CASE PRESENTATION: A forty-year-old Filipino woman presented to our center with recurrent VCCC that had progressed on multiple prior lines of cytotoxic chemotherapy. She had a large 25 cm fungating left groin tumor causing marked lower limb lymphedema, pain and limited mobility. PD-L1 CPS by immunohistochemistry was 45. She was treated with off-label pembrolizumab monotherapy and had a dramatic clinical, biochemical and radiological partial response. The progression-free survival of this patient's VCCC after treatment with pembrolizumab, defined as the time from initiation of pembrolizumab until disease progression (by Response Evaluation Criteria in Solid Tumors (version 1.1)), was 8 months. While receiving pembrolizumab, she was diagnosed with concurrent secondary myelodysplastic syndrome with excess blasts (MDS-EB), thought to be related to her prior exposure to multiple lines of cytotoxic chemotherapy. This eventually progressed to acute myeloid leukemia (AML), leading to her demise. Overall survival from time of initiation of pembrolizumab till death was 16 months. CONCLUSION: Pembrolizumab was active in this patient with chemotherapy-refractory VCCC which harbored high PD-L1 CPS. Further studies to determine the role of immune check-point blockade in the treatment of VCCC are warranted.

A comparison of the feasibility and safety of nerve-sparing radical hysterectomy with the conventional radical hysterectomy.

BACKGROUND: Radical hysterectomy has been the treatment of choice for early-stage cervical cancer. Since its introduction in oncology, modifications to the original technique were made to enhance feasibility, improve cure rate, and decrease postoperative complications. Among these are the identification and preservation of pelvic autonomic nerves, known as the nerve-sparing radical hysterectomy (RH). This retrospective study was conducted to compare the nerve-sparing with the conventional RH in terms of feasibility and safety, including bladder dysfunction and perioperative and postoperative complications and morbidities. METHODS: Patients with biopsy-proven early-stage cervical carcinoma, cervical carcinoma with central tumor recurrence or persistence after primary radiotherapy, and endometrial carcinoma with cervical involvement treated with RH with or without nerve-sparing technique were included. The perioperative and postoperative complications and bladder function of these patients were analyzed. RESULTS: Ninety-seven patients with early-stage cervical cancer and 24 patients with clinical stage II endometrial cancer underwent RH with or without nerve-sparing technique in a nonrandomized fashion. There was no statistically significant difference between the 2 procedures in terms of duration of surgery, intraoperative blood loss, duration of hospitalization, and morbidity. Patients who underwent the nerve-sparing approach had a statistically significant earlier return of bladder function, with a mean of 9.4 days for the cervical cancer cases (vs 21 days in the non-nerve-sparing group) and a mean of 8.5 days for the endometrial cancer cases (vs 22.6 days in the non-nerve-sparing group). CONCLUSIONS: The technique of sparing the pelvic autonomic nerves during RH for early-stage cervical cancer and clinical stage II endometrial cancer is comparable to the conventional method in terms of perioperative complications and morbidity, but is more favorable in terms of return of bladder function.

Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control.

This paper aims to provide evidence-based recommendations for health professionals, to develop a comprehensive cervical cancer program for a clinic, a community, or a country. Ensuring access to healthcare is the responsibility of all societies, and the Asia Oceania Research Organisation in Genital Infections and Neoplasia (AOGIN) is committed to working collaboratively with governments and health professionals to facilitate prevention programs, to protect girls and women from cervical cancer, a disease that globally affects 500,000 and kills nearly 300,000 women annually, just over half of whom are in the Asia Oceania region. We share the vision that a comprehensive program of vaccination, screening, and treatment should be made accessible to all girls and women in the world. The primary purpose of these guidelines is to provide information on scientific evidence on the different modalities and approaches of cervical cancer prevention programs, for high resource and low resource settings. The secondary purpose is to provide an overview of the current situation of cervical cancer control and prevention in various Asian Oceania countries: their views of an ideal program, identified obstacles, and suggestions to overcome them are discussed.

Epidemiology, prevention and treatment of cervical cancer in the Philippines.

Cervical cancer remains to be one of the leading malignancies among Filipino women. High-risk human papillomavirus (HPV) types, such as 16 and 18, are consistently identified in Filipino women with cervical cancer. Factors identified to increase the likelihood of HPV infection and subsequent development of cervical cancer include young age at first intercourse, low socioeconomic status, high parity, smoking, use of oral contraception and risky sexual behaviors. Cancer screening programs presently available in the Philippines include Pap smears, single visit approach utilizing visual inspection with acetic acid followed by cryotherapy, as well as colposcopy. However, the uptake of screening remains low and is further compounded by the lack of basic knowledge women have regarding screening as an opportunity for prevention of cervical cancer. Prophylactic HPV vaccination of both quadrivalent and bivalent vaccines has already been approved in the Philippines and is gaining popularity among the Filipinos. However, there has been no national or government vaccination policy implemented as of yet. The standard of treatment of cervical cancer is radiotherapy concurrent with chemotherapy. Current researches are directed towards improving availability of both preventive and curative measures of cervical cancer management.

Epidemiology and prevention of cervical cancer in Indonesia, Malaysia, the Philippines, Thailand and Vietnam.

Cervical cancer remains one of the leading causes of cancers in women from Indonesia, Malaysia, the Philippines, Thailand and Vietnam. High-risk human papillomavirus (HPV) types, particularly HPV-16 and 18, are consistently identified in cervical cancer cases regardless of geographical region. Factors that have been identified to increase the likelihood of HPV exposure or subsequent development of cervical cancer include young age at first intercourse, high parity and multiple sexual partners. Cervical cancer screening programs in these countries include Pap smears, single visit approach utilizing visual inspection with acetic acid followed by cryotherapy, as well as screening with colposcopy. Uptake of screening remains low in all regions and is further compounded by the lack of basic knowledge women have regarding screening as an opportunity for the prevention of cervical cancer. Prophylactic HPV vaccination with the quadrivalent vaccine has already been approved for use in Malaysia, the Philippines and Thailand, while the bivalent vaccine has also been approved in the Philippines. However, there has been no national or government vaccination policy implemented in any of these countries.

Recommendations for cervical cancer prevention in Asia Pacific.

Asia Oceania includes countries from both the Asia Pacific region and Australasia, which cover very diverse geographical areas and populations as well as bearing 52% of the cervical cancer burden in the world. Human papillomavirus (HPV) genotype distribution in women with normal cytology varies between countries in this region, as well as with the distribution typically observed in worldwide estimates or in Western countries. HPV-16 remains the predominant oncogenic type for high-grade cervical dysplasia and cervical cancer across the region, and HPV-18 is generally among the five most common types. HPV-58 is commonly found in cervical cancer as well as in women with normal cytology, and HPV-31, 33 and 35 are relatively less frequent in these regions compared to the West. While screening programmes have been proposed and implemented in several populations, successful programmes are rather limited and the majority of countries still have no or minimal screening services. Prophylactic HPV vaccination will only be feasible when it becomes affordable, thus the current priority and the short-term goal for cervical cancer control is to identify feasible and effective screening measures, and to find the most effective way to combine vaccination with sustainable screening programmes. This Regional Report has carefully described the disease burden of HPV and cervical cancer and the current situations in cervical cancer prevention for many countries in the Asia Oceania region. These data identify the many challenges and opportunities to be considered for policy decisions for cervical cancer control. Furthermore, this report presents the results of advanced decision analytic models calibrated to countries in the region that provide early insight into what strategies are most promising and those likely to be cost-effective and affordable. It thus provides a synthesis of the available evidence-based scientific information, in the context of a significant and systematic international review, that is likely to be useful to governments and public health providers.

The endometrial cancer risk scoring / Philippine Journal of Obstetrics and Gynecology

Our objectives were to determine the most significant prognostic factors affecting node metastasis in endometrial cancer and to devise and validate a scoring system for endometrial cancer. The study design consisted of retrospective chart review (operative record and histopathology report) of all endometrial cancer patients who underwent total hysterectomy/radical hysterectomy, bilateral salpingooophorectomy, bilateral pelvic lymph node dissection and peritoneal fluid cytology from September 21, 1989 to February 19, 1999. The analysis included 262 women, 21.4% of whom had pelvic lymph node metastasis.The mean ages for those with metastasis and without metastasis were similar positive lymph node (LN) =53.18 years old; negative LN=51.89 years old; range: positive LN=31-84 years old, negative LN=23-76 years old. Most patients were of low gravidity, with mean=G3, median=G4, mode = GO. The most significant factors affecting pelvic lymph node metastasis were peritoneal fluid cytology, myometrial invasion, cervix involvement and histologic grade as determined by logistic regression and Odds ratio. A prognostic scoring system was devised. All subjects were scored according to a proposed scoring system to determine the latter's clinical utility. A cut-off score of 5 was shown to be significant for pelvic lymph node metastasis. The proposed scoring system may be used to determine the likelihood of pelvic lymph node metastasis for patients who did not have lymphadenectomy and may have an important role in determining the need for adjuvant treatment.