Introduction

The knowledge that persistent human papillomavirus (HPV) infection is the main cause of cervical cancer has resulted in the development of prophylactic vaccines to prevent the HPV infection and HPV assays that detect the virus Given the recent call from WHO to scale up preventive, screening and treatment interventions to eliminate cervical cancer as a public health problem during this century, it is timely to assess the current burden of the disease as a baseline from which to assess the impact of the global initiative.

Methods

Visual and tabular descriptions of national estimates of cervical cancer incidence and mortality in 2018 are presented from GLOBOCAN, the recently compiled database from IARC of cancer estimates for 185 countries.

Results

There were an estimated 570,000 cases of cervical cancer and 311,000 deaths from the disease in 2018. It is the fourth most common female cancer ranking after breast cancer (2.1 million cases), colorectal cancer (0.8 million cases) and lung cancer (0.7 million). The incidence of cervical cancer varies widely among countries with estimated world-age-standardised rates ranging from less than 1 to 75 per 100,000. Cervical cancer is the leading cause of cancer-related death among women in Eastern, Western, Middle and Southern Africa. The highest incidence rate is estimated in the Kingdom of Eswatini, with ~ 6.5% of women developing cervical cancer before the age of 75. China and India contribute over one third of the global cervical burden with 106,000 and 97,000 cases and 48,000 and 60,000 deaths, respectively. More than the other major cancers, the disease affects women <45 years.

Conclusions

Cervical cancer continues to be a major public health problem affecting young women particularly in low and middle-income countries. The global scale-up of HPV vaccination and HPV-based screening – including self-sampling – may make cervical cancer a rare disease in the decades to come.

Introduction

The World Health Organization (WHO) global call for action towards the elimination of cervical cancer (CC) as a public health problem involves setting ambitious screening and vaccination coverage targets. The draft WHO strategic plan for elimination proposes a CC incidence target of 4/100,000 women per year. We performed a comparative modeling analysis using two models from the Cancer Intervention and Surveillance Modeling Network (CISNET) consortium to explore the impact of reaching vaccination and screening coverage levels outlined by the WHO, as well as other potential strategies.

Methods

We performed a comparative modeling analysis that used two independently-developed CISNET models (Harvard and Policy1-Cervix) to project CC incidence rates per 100,000 women over time associated with alternative HPV vaccination and screening scale-up scenarios. Both models involved a dynamic multicohort-modeling platform to capture changes in human papillomavirus (HPV)-induced CC over time, including herd effects from vaccination. We explored the impact of alternative standard population structures, inter alia.

Results

Under status quo assumptions, both models projected that CC incidence would fall below 4/100,000 women by year 2038-2046. Scaling-up screening coverage to 90% by 2020 was the most impactful intervention in terms of elimination timing and relative cancer reductions, averting an average of 1,350-2,230 additional cases per year over 2020-2100. Sensitivity analysis using different population structures generated a range around these predictions. Increasing HPV vaccination coverage to 90% or vaccinating adults aged 26-45 years had nominal impacts on cancer incidence.

Conclusions

These validated CISNET-cervical models, which reflect uncertainty in the natural history of CC, found that national CC incidence rates may fall below 4/100,000 women by 2046, but this could be expedited if screening coverage is improved. These national estimates do not apply to all subgroups of women; therefore, reaching under-screened and under-vaccinated women remain key to achieving CC elimination for all women.

Introduction

Interval cervical cancer is an invasive carcinoma following a normal Papanicolaou smear, in patients with a negative history of cervical-cancer screening. It is a rare entity with no specific risk factors, however it is associated with a persistence of HPV infection.
The purpose of this study was to analyse those cases of invasive cervical cancer diagnosed during an opportunistic screening of women with at least one normal cytology in the previous 3 years.

Methods

A retrospective descriptive study which included data of women diagnosed of rapid-onset cervical cancer in the Lower Genital Tract Pathology Unit of the Mother-and-Child University Hospital Complex of the Canary Islands, in a 10-year period.

Results

Interval cervical cancer was detected in 57 patients with negative cervical cancer screening. The most common histological result was squamous cell carcinoma (56%), and the rest had a glandular component (adenocarcinoma or adenosquamous carcinoma). The clinical stage at the moment of the diagnosis was IB1 in 61%.

The main cause of referral was high grade squamous intraepithelial lesion (HSIL), in 44%. 56% were HPV 16 DNA-positive. The most common symptom was vaginal bleeding.

The mean age was 47 years, 18% of women were nulliparous, 23% reported long-term oral contraceptive use, 33% were active smokers. Approximately half of the patients had more than ten cytologies throughout their life and most of them had normal cytologies in the last two years.

Conclusions

Interval cervical cancer is a not-so-rare entity, especially in the context of opportunistic screening. These data prove the inefficacy of cytology in the detection of glandular lesions.

In order to solve this problem, it would be advisable to act on two levels of prevention: on the one hand, to improve vaccine coverage rates and on the other, to establish a population-based screening with HPV test in women over 35 years.

Introduction

Despite being preventable, cervical cancer (CC) remains a public health challenge in the United States. Annually, 13,170 new cases of invasive CC are diagnosed and 4,250 women die. Hispanic and African-American women are disproportionately affected. Vaccine uptake and screening reduce incidence and death. Approximately, 95% of CC is caused by human papillomavirus (HPV). Most HPV clears naturally. The association of HPV genotypes with race and neighborhood-level factors is not explored. We aim to explore the link between structural violence as expressed by exposure to residence in high stress, violence, poverty and HPV prevalence in 24 Chicago neighborhoods.

Methods

After obtaining IRB approval, we established a database of 13,466 patients residing in 24 Chicago neighborhoods who underwent 41,378 cervical screening tests over five years (Jan 2013 - Dec 2018). Data was imported into RedCap from an enterprise data warehouse (EDW). The main dataset will be critical in linking patient medical information to neighborhood-level epidemiological information. Preliminary analysis of 4,763 patients completed and full analysis to be finalized by December 2019.

Results

Of 4,763 patient records coded, 3,502 women underwent HR-HPV tests and 708 tested positive for HR-HPV (20.2%). African Americans made up 50.1% of the 4,763 coded cases and 55.2% of the HR-HPV positives. HR-HPV prevalence ranges from 36.4% in Fuller Park to 3.9% in West Elsdon. Correlation analysis shows that HR-HPV is associated with CC death, but not incidence. It is also associated with percentage African American. Chlamydia, gonnorhea, syphillis and HIV are associated with HR-HPV as are poverty and homicide. These latter factors may cause increased cortisol that facilitates HR-HPV resilience and progression to CC.

Conclusions

Our study examines the distribution of HPV across neighborhoods in a large urban setting. Correlation of HPV with demographic and neighborhood-level data, particularly structural violence factors, may help better understand likely facilitators of HPV and CC.

Introduction

The WHO has recently called for coordinated action to eliminate cervical cancer globally. Although it has been estimated that the impact of elimination strategies will prevent around 13 million cervical cancer cases globally by 2070, the wider impact on other HPV-related cancers had not been analysed. Large scale uptake of the HPV vaccine will have the additional benefit of preventing other cancers caused by HPV, such as a proportion of vulvar, vaginal, anal, penile and oropharyngeal cancers. In this study we aim to expand the analysis of cervical cancer elimination to also capture its effect on these other cancers.

Methods

A deterministic incidence-based model was developed to estimate the reduced burden of other HPV cancers. The proportion of each cancer attributable to HPV types targeted by the vaccine was obtained using published estimates. The HPV incidence reductions predicted by previously published elimination studies were then applied to the HPV attributable cancer incidence, resulting in an estimated cancer incidence reduction. Age and sex specific cancer incidence rates were used.

Results

If the cervical cancer elimination targets of 90% female HPV vaccination for ages 9-14, the incidence of other-HPV related cancers will be reduced by 20-29% globally in 2070.

Conclusions

If achieved, the global push for cervical cancer elimination will have an additional, previously unquantified, societal benefit of reducing the global burden of other cancers associated with HPV by 20-29% by 2070, on top of preventing the previously reported 13 million cervical cancer cases.

Introduction

Innovative devices are often targeted at increasing access, improving quality, or reducing costs — the three axes of the infamous 'Iron Triangle of Health Care' which are notoriously difficult to simultaneously optimize. The main aim of this study was to demonstrate that disruptive technologies, if high-quality and appropriately implemented, can result in improved access, cost, and quality of care — overcoming the conventional constraints of the Iron Triangle framework.

Methods

Our team conducted a global value chain (GVC) analysis of the Pocket Colposcope in Lima, Peru and developed surveys and in-depth interviews to evaluate Pocket Colposcope stakeholders. All surveys were developed with consultations from the Duke Evidence Lab and had IRB approval.

Results

GVC identified five leverage points: regulatory approval, task-shifting, collaboration, telemedicine, and patient acceptance. We also indentified stakeholders and processes impact the degree to which the Pocket Colposcope is successfully implemented. 39.4% of women surveyed answered that they had previously wanted a cervical cancer screening test, but had been unable to receive one due to some barrier. The most common responses were distance to clinics (31.0%), participants could not leave work (27.6%), and patients were afraid of receiving a cancer diagnosis (20.7%). All four midwives who participated in the focus group identified the portability of the Pocket Colposcope as the device's most appealing feature. Providers identified the quality of the image, cost to patient, and ease of use as the three most important aspects of the Pocket Colposcope.

Conclusions

The Pocket Colposcope provides an opportunity to make high quality diagnostic technology more accessible at a cheaper price for more people. Often, disruptive technology in low-income settings is expected to increase access at the cost of reducing quality. In the case of the Pocket Colposcope, the disruptive technology is significantly cheaper than existing technology, but is still high quality enough to succeed.

Introduction

Methods based on artificial intelligence (AI) have enormous potential for cervical cancer management in low resource settings (LRS), by reducing operator bias at the point of care. However, few implementations of AI in medicine have been successfully deployed in LRS to date. This study aimed to examine an AI point of care tool for clinical management.

Methods

In this study, a clinical decision support (CDS) AI classifier was tested in a screening camp in Inner Mongolia, China. The CDS classifier was built from an existing image set from 1473 colposcopy patients labeled by three colposcopy experts, with an area under the (ROC) curve of 0.93, and runtime <1 sec. CDS was implemented as a function called from the web once images were synced from an Android application. Using a local 3G network, images were uploaded from the colposcope into a secure image portal, from which CDS was accessed. CDS processed all images of sufficient quality from the same patient session, and aggregated the scores using a weighted average. Using this implementation, classifier results were available in minutes.

Altogether, images were collected from N=147 patients. Upon patient enrollment, cervical images were captured using a mobile colposcope for classification analysis. Patients flagged by CDS or those with visible lesions after the application of acetic acid, were biopsied.

Results

CDS was able to make a prediction for 145 of 147 imaged patients. Colposcopic impressions were available for 130patients and of the 128 patients with both colposcopic impressions and CDS results, disagreements were found in 16 patients, demonstrating high agreement rates between CDS and colposcopic impressions. Biopsy results are pending.

Conclusions

The first utilization of real-time AI for patient management at the point-of-care in LRS, these results suggest that AI can provide an immediate answer consistent with colposcopic impressions, at the point-of-care in screening programs in LRS.

Introduction

Both the Sustainable Development Goals and the WHO call for cervical cancer elimination include screening coverage in adult women as a monitoring indicator. However, global estimates are still unavailable. We aim to produce comparable global/regional standardized estimates of cervical screening coverage, and to assess current achievements and gaps and their potential impact for monitoring global disease reduction.

Methods

We run a systematic review on national cervical screening programs, with support from professional translators. Retrieved information includes program characteristics and age-specific screening coverage rates. Data are further cross-checked with WHO, IARC, and HPV Information Centre databases. Women grouped by one-year age and country strata are assigned with a 2019 screening coverage rate, applied to United Nations population estimates and pooled to obtain global rates. Imputation algorithms adapted to the complexity of cervical screening are being developed, including predictive mean matching and other missing-data treatment techniques.

Results

As of July 2019, 58 countries have been reviewed. We are reporting on the first two areas completed (Arab-speaking (AS-countries) and post-Soviet states (FSU-countries). Most AS-countries lack national screening programmes, except for the Maghreb region. Most FSU-countries have cytology-based screening, and half send personal invitations. Less than 20% of women aged 30–49 in AS-countries have ever been screened, while over 65% in FSU-countries have. At the meeting, detailed results on program characteristics and global coverage estimates will be presented.

Conclusions

This work will answer essential questions for global health governance and monitoring of the elimination campaign such as the extent and characteristics of screening programs worldwide, or the number of women that will need to be screened for the first time in the next 5-years. Main challenges are the variability and complexity of screening data. Adaptation of a previously developed methodological approach to produce global HPV-vaccination coverage estimates may prove useful to quantify global screening practices.

Introduction

Cervical cancer is one of the most preventable and treatable forms of cancer. WHO issued a global call to action in May 2018 to eliminate cervical cancer as a global public health problem. As a member of the UICC, The Partnership is now leading the charge to create a 10-year pan-Canadian action plan to eliminate cervical cancer and will host a summit to launch the plan in Feb 2020.

Methods

OncoSim is a microsimulation model, led and supported by the Canadian Partnership Against Cancer, with model development by Statistics Canada, and is made possible through funding by Health Canada. The OncoSim-Cervical and HPV Microsimulation Model (HPVMM) is a specific OncoSim module that focuses on the prevention, screening, diagnosis and treatment of cervical cancer.

Taking a health system perspective, using OncoSim, we seek to: (i) project the potential health and economic impact associated with achieving the target of 90/90/90 by 2030: 90% HPV vaccination, 90% catch-up vaccination, and 90% cervical cancer screening participation in an eligible population by 2030 in Canada. (ii) Assess the likelihood of meeting the 2040 goal to eliminate cervical cancer (less than 4/100,000, crude) in Canada with the implementation of coordinated HPV vaccination programs, HPV vaccination catch-up programs, and cervical cancer screening programs using HPV testing.

Results

Costs and health outcomes will be evaluated in a short-term frame (2020-2030), as well as longer-term (2020-2040) to align with the elimination of cervical cancer targets

Incidence and mortality rates, resource utilization (screen numbers, colposcopies etc.) and rates of dysplasia will also be reported

Conclusions

The Canadian Partnership Against Cancer is actively works with its partners to lead the way towards elimination. Over the last five years, OncoSim’s projections have helped inform cancer control planning decisions across Canada and the results from this analysis will help inform the Pan-Canadian action plan.

Introduction

Elimination of cervical cancer by 2030 is a key global objective proposed by WHO. Canadian experts have determined that, to achieve this goal, the Montreal Global HPV prevention objectives need to be met in the targeted population;

· 90% of girls fully vaccinated with the HPV vaccine by 15 years old;

· 90% of women screened with an HPV test; and

· 90% of women identified with cervical disease receive treatment and care.

Methods

A group of 20 prominent international HPV/cervical cancer experts attended a planning workshop and created a report on Canada’s role in accelerating global elimination of cervical cancer.

National/international recommendations have been made to the Canadian Government that would enable Canadians to become major contributors in efforts to attain the goals set by WHO.

Results

Canadian experts have the scientific expertise and the tools to reach the WHO 2030 objective of decreasing cervical cancer incidence to fewer than 4 per 100,000. The main challenge in the planning of cervical cancer elimination is to secure funding and political support.

In order to reach this ambitious objective, innovative approaches must be developed with community leaders to bring the reality of cervical cancer elimination to all communities but especially to communities that experience higher rates of cervical cancer.

Conclusions

Canada should assume international leadership for cervical cancer elimination. Over 100 recommendations for action have been proposed within this important document. Two powerful tools exist for this drive to cervical cancer elimination by 2030: HPV prophylactic vaccines and cervical cancer screening. To take the greatest advantage of these tools, knowledgeable experts must be involved and efforts expedited to implement at least some of these recommendations. If there are delays, the international cervical cancer elimination objective will not be met, with the possible exception of a few rich countries that are already approaching the goal.

Introduction

Cervical cancer is the second cancer in women from Sub Sahara Africa. The aim of this study was to evaluate the impact of free of charge cervical cancer screening each weekend during18 months in Bamako, Mali.

Methods

We conducted a cross-sectional from cervical cancer screening data the District of Bamako from January 1st, 2010 to December 31st, 2017. The target population was women aged 20 years or higher. We included 27 healthcare structures where cervix screening is routinely available for clients. From July 2016 to December 31st, 2017 we used communications lines to reinforce adherence to screening, and screening services were free a charge each weekend during this period. Descriptive statistics were calculated.

Results

During the study period, 182 741 women were screened for cervical cancer in the District of Bamako. Among these, 145,000 women were screened during the period of free of charge services. Screening coverage has increased from 35% between 2010 - 2015 to 46% in 2016 - 2017. The age groups 20-24, 25-29, 30-34 and 35-39 years old were the most represented; while women aged 65 and over were less represented. Prevalence rate of precancerous lesions was 2.7% and 1.1% for cancerous lesions. Since 2017, we observed a significant decrease of annual prevalence rate of precancerous and cancerous lesion. There was a significant decrease in the prevalence rate of invasive cervical cancer. This decrease was mainly observed for advance stages III and IV.

Conclusions

A well organized screening program is feasible in developing settings and can decrease the burden of cervical cancer.

Introduction

HPV is the leading cause of cervical cancers, with an increasing risk associated to HIV in developing countries. This study aimed at comparing HPV positivity, circulating genotypes and its determinants among women following their HIV status.

Methods

A comparative study was conducted in 2012 at the Chantal BIYA International Reference Centre, among 278 women enrolled consecutively in two reference hospitals of Yaoundé. HPV genotyping, , HIV serological screening, HIV viral load and CD4-count were performed.. Statistical analyses were performed using Microsoft Excel 2016 and Graph Pad version 6.0 software; with P<0.05 considered statistically significant.

Results

Globally, mean age was 37 ±3 years; median CD4-count for HIV+ was 414 cells/mm³ [IQR: 264.75-588] and median viremia was 50 RNA copies/mL [IQR: <40-8288]. Following HIV status, HPV rate was 43.47% (80/184) among HIV+ vs. 28.72% (27/94) among HIV- (OR: 1.937; p<0.0142); HPV genotypes among HIV+ vs. HIV- were respectively distributed as follows: genotype 16 (3.75% vs. 0.00%, p=0.57), genotype 18 (3.75% vs. 3.70%, p=1.00), co-infection 16 and others (8.75% vs. 7.40%, p=1.00), co-infection 18 and others (8.75% vs. 11.11%, p=0.71), co-infection 16, 18 and others (2.50% vs. 0.00%, p=1.00) and other genotypes (72.50% vs. 77.78%, p=0.80). Among HIV+ participants, HPV rate following CD4 was 62.88% (61/97) for CD4<500 vs. 35.71% (20/56) for CD4≥500 (OR: 3.05; p=0.0012) while HPV rate following HIV viremia was 42.71% (41/96) with <1,000 RNA copies/ml vs. 66.00% (33/50) with >1,000 RNA copies/ml (OR= 0.384; p =0.009).

Conclusions

In Yaoundé, HPV rate was very high, with higher rates of genotypes other than 16 and 18 in circulation. In the event of HIV infection, the risk of HPV positivity is two times higher, favoured by immunodeficiency and high HIV-viremia. Thus, HIV-infected women should be closely monitored to prevent the emergence of cervical cancer.

Introduction

There is scarcity of data about human papillomavirus (HPV) in female sex workers (FSWs) in Sub Sahara Africa. This study aimed to: (1) assess the prevalence and genotype distribution of HPV among FSWs; (2) evaluate factors associated with low-risk (LR) and high risk (HR) HPV types.

Methods

This is a Baseline data from 312 FSW recruited during a longitudinal study in Cotonou from 2017 to 2018. The Linear Array HPV genotyping test (LA-HPV) (Roche Molecular Systems) was used to identify the HPV genotypes. The cross-reactivity between HPV52 and HPV-33, 35 or 58 was further tested with a real-time PCR assay specific for HPV52. Descriptive statistics and logistic regression were used. Adjusted Odd ratios (aOR) with 95% confidence intervals (95%CI) were estimated.

Results

HPV data were available for 309 FSWs. The mean age was 34.97 years (± 10.66) and the first sexual debut was 17.53 years (± 2.66). HIV, gonorrhea and chlamydia prevalence rates were 25.8%, 13.8% and 7.4%, respectively. At least one HR-HPV was found in 269 women (87.1%). The five most prevalent HR-HPV were: HPV58 (37.5%), HPV16 (36.6%), HPV52 (28.8%), HPV35 (23.3%), HPV45 (15.2%). At least 239 women (77.4%) had one LR-HPV and the five most prevalent were: HPV62 (35.6%), HPV81 (23.6%), HPV61 (23.0%), HPV84 (16.2%) and HPV72 (15.2%). The main factors associated with HR-HPV infections were age 20 to 30 years (aOR = 4.62; 95%CI: 1.13 – 18.9), separated/widow (aOR = 4.17; 95%CI: 1.36 – 12.82) and single women (aOR = 5.00; 95%CI: 1.16 – 21.51). Factors associated with LR-HPV were HIV infection (aOR = 2.91; 95%CI: 1.20 – 7.06), single women (aOR = 3.60; 95%CI: 1.35 – 9.60) and vaginal washing (aOR = 2.27; 95%CI: 1.10 – 4.71).

Conclusions

These data confirmed the necessity to emphasize on cervical cancer prevention in FSWs in Sub Sahara Africa.

Introduction

A powerful motivation to screen for cervical cancer (CC) is personal awareness of risk. Previous studies shows that in Mali, a country suffering from both low levels of literacy and high rates of CC, knowledge about CC and the underlying risk factor, infection by Human Papillomavirus (HPV) is low. This interventional study evaluated the impact of an initiative by GAIA Vaccine Foundation (GAIA VF) to improve cervical cancer (CC) awareness utilizing a “storytelling” textile design for a community awareness campaign and offering free CC screening in Bamako, Mali.

Methods

During the six-month campaign, healthcare providers and community health workers led weekly education sessions on CC, the connection between HPV and CC, and the HPV vaccine, in health clinics and surrounding communities while dressed in a “storytelling” cloth. The cloth print illustrates the connection between viral infection of HPV and the development of CC in a colorful West African wax print style. Effectiveness of the campaign was assessed by surveying women seeking CC screening at the partnering clinics.

Results

CC screening during the campaign increased fivefold. Survey results show that 52% of women cited the education sessions where the storytelling cloth was displayed as their reason for visiting the clinic more often than any other form of outreach. Participants’ desire for vaccination (of girls) was high and overwhelmingly driven by knowledge obtained through the storytelling cloth campaign. The cost of the intervention was $33 per woman screened, and 3,271 women successfully completed screening during the six-month period.

Conclusions

This culturally relevant, visually based approach for improving health literacy could be applied to future health campaigns by linking educational outreach to diagnostic and treatment services.

Introduction

Due to distinctive immunogenic properties of human papillomavirus virus like particles (HPV VLPs) HPV vaccination generates a durable antibody response producing high-quality neutralizing antibodies. The viral survival strategy which includes hiding from the systemic immune system, is overruled by intramuscular injection generating huges amounts of vaccine induced antibodies. As other circulating immuno globulines G, vaccine inducted IgGs, are easily transuded to the genital mucosa and are detectable in genital secretions.

Methods

It is well accepted that these antibodies interact with the virions presented by an infected partner and inhibit infection.

Results

However, much less attention has been paid to the role of anti-HPV vaccine-induced antibodies in HPV-infected individual where infectious virions are encountered by neutralizing antibodies in mucosal secretions. Indeed, in these women vaccination may interfere with the auto-innoculation obstructing infectious virions to spread from sites with low potential for malignant progression to the transformation zone with higher potential for progression. Secondly, anti-HPV IgGs may potential also decrease the likelihood that women with a productive infection transmit the infection to their sexual partner.

Conclusions

Although it is challenging to investigate experimentally or epidemiologically this concept because of it potential impact there is a clear need to further investigate and document this concept. Indeed, if HPV vaccination of HPV-infected women has an effect on HPV transmission, auto-inoculation, and relapse after treatment this may influence how we model, assess and implement HPV vaccination programmes.

Introduction

AmpFire HPV screening assay designed and developed with the developing world in mind. The assay demonstrated that is very simple to run and very inexpensive, and good for dry brush transport to be used with self-collected vaginal samples. Self-collection can become an important addition to population based cervical cancer screening programs as the primary screen in LMIC. Objective of this presentation is to share the evolution of designing and developing the AmpFire HPV screening technology suitable for LMIC and lesson learned for how to transfer the AmpFire technology to LMIC.

Methods

The AmpFire Multiplex HR HPV Screening assay detects 15 HR HPV and simultaneously genotypes HPV 16 and 18 in one reaction with isothermal real time fluorescent detection. Simple assay protocol by adding 1ml buffer to the dry brush sample tube with vortexing and waiting for 20 minutes at room temperature, the sample is then ready for detection. The HPV results are automatically reported by AmpFire detection system within an hour.

Results

In resource-limited environments, self-collection and dry brush samples overcome many of the barriers comparing to use of alcohol-based liquids for cervical cancer screening. AmpFire HPV assay was used in Inner Mongolia to screen 1400 women in two days with an overall positive rate of proximately 18% on self-collection dry swabs. The workflow will be discussed and experience and lesson learned to transfer AmpFire HPV assay to LMIC will be shared.

Conclusions

AmpFire HPV assay is suitable for being used in LMIC for large population screen. It is affordable at a fraction of the cost of common assays. To use dry swab sampling is much easy to collect. The test is simple to perform with minimal training. Sample to result is about an hour that is fast enough to enable treatment of the patient during the visit.

Introduction

HPV-and-Treat approach incorporating self-sampling HPV test and thermal ablation seems to be pragmatic in low-resource areas. However, overtreatment and undertreatment remain problems to be resolved. We aimed to identify promising biomarkers that could be incorporated into HPV-and-Treat approach to achieve a balance between overtreatment and undertreatment.

Methods

9,526 women were recruited in China in 2017. Participants received self-sampling hrHPV tests at baseline. HrHPV-positive women underwent colposcopy, biopsy and thermal ablation within a single visit at baseline and have been followed up one year later. HPV genotyping, HPV16/18 E6 oncoprotein and targeted human genes (ASTN1/DLX1/ITGA4/RXFP3/SOX17/ZNF671) methylation assays were performed among hrHPV-positive women. We evaluated overtreatment and undertreatment of the HPV-and-Treat approach with HPV primary screening and HPV screening followed by colposcopy or biomarker triage classifiers among hrHPV-positive women at baseline. Overtreatment was defined as treatment in patients with no CIN. Undertreatment was defined as no treatment in patients with CIN.

Results

1,711 hrHPV-positive women were included in the final analysis. The overall overtreatment rate in women with abnormal colposcopy was 42.1%(95%CI35.3-49.1%), which could be minimized to 8.5%(95%CI3.4-19.9%) after triaging HPV positives with HPV16/18 E6 oncoprotein, with undertreatment rates of 7.1%(95%CI5.9-8.5%) and 10.6%(95%CI9.2-12.2%), respectively. The overtreatment rate was 16.7% in women with HPV16/18 infection and abnormal colposcopy, and 27.4% in women with positive human gene methylation and abnormal colposcopy, with similar undertreatment rates (9.5% vs 9.3%). For an assumptive approach with self-HPV test followed by treatment directly, the overtreatment rate reached up to 82.1%(95%CI80.3-83.9%), which were still up to 77.2% and 64.1% after triaging by human gene methylation and HPV16/18 genotyping. A significant decline was observed by triaging with colposcopy (42.1%,95%CI35.3-49.1%) and HPV16/18 E6 oncoprotein (27.9%,95%CI20.2-37.2%), with the undertreatment rates of 7.1% and 9.1%.

Conclusions

HPV16/18 E6 oncoprotein was a promising biomarker that could be incorporated into the HPV-and-Treat approach to balance overtreatment and undertreatment.

Introduction

Cervical cancer is the second leading cause of cancer death for women in the Dominican Republic. Pap smear screening in the Dominican Republic has not achieved adequate reduction in cervical cancer mortality. The purpose of this study was to examine Dominican provider practices for cervical cancer screening and the use of national or international screening guidelines.

Methods

We surveyed 101 gynecology specialists, 50 non-specialists, and 51 obstetrics-gynecology residents in the Santo Domingo and Monte Plata provinces of the Dominican Republic regarding their cervical cancer screening practices and use of guidelines. Bivariate (chi-square) analyses were conducted to compare screening practices by demographic and practice characteristics.

Results

The majority of providers followed WHO guidelines (62.9%) and/or Dominican national norms (59.4%). The majority (87%) of providers use time since first sexual activity as the basis for screening initiation; 96% advise screening every 6-12 months. The most commonly used screening test is the conventional Pap smear. Colposcopy was recommended most often for all abnormal Pap results.

Conclusions

Dominican providers report they follow national and/or international cervical cancer screening guidelines. They do not follow age-based screening guidelines, nor have they adopted an extended interval for screening and continue to recommend screening at least annually. A culture of early and frequent screening has consequences in terms of cost, high demand for follow up services, and reduced capacity to reach the populations at highest risk. Early screening also may challenge the acceptability of adopting alternative screening technologies such as HPV testing.

Introduction

Creating effective programs for cervical cancer prevention is essential to avoid premature deaths from cervical cancer. The Dominican Republic has persistently high rates of cervical cancer, despite the availability of Pap smear screening. This study explored Dominican provider attitudes towards HPV testing and current challenges to effective cervical cancer prevention.

Methods

In this CFIR-driven mixed methods study, we conducted in-depth interviews (N=21) and surveys (N=202) with Dominican providers in Santo Domingo and Monte Plata provinces regarding their perspectives on barriers to cervical cancer prevention and their knowledge and attitudes towards HPV testing as an alternative to Pap smear.

Results

Providers believed the main barrier to cervical cancer prevention was lack of cervical cancer awareness and resulting inadequate population screening coverage. Providers felt Pap smear was widely available to women in the Dominican Republic and were unsure how a change to HPV testing for screening would address gaps in current cervical cancer screening programs. A subset of providers felt HPV testing offered important advantages for early detection of cervical cancer and were in favor of more widespread use. Cost of the HPV test and target age for screening with HPV testing were the main barriers to acceptability.

Conclusions

Providers had limited knowledge of HPV testing as a screening test. The group was divided in terms of the potential impact of a change in screening test in addressing barriers to cervical cancer prevention in the Dominican Republic. Findings may inform interventions to disseminate global evidence-based recommendations for cervical cancer screening.