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Brooks Cooper
Brooks Cooper

Cervical Cancer Screening And Management Of Cer... __EXCLUSIVE__


When diagnosed, cervical cancer is one of the most successfully treatable forms of cancer, as long as it is detected early and managed effectively. Cancers diagnosed in late stages can also be controlled with appropriate treatment and palliative care.




Cervical cancer screening and management of cer...


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The virtual course on comprehensive cervical cancer control is designed to promote education and training for health providers in the prevention and control of cervical cancer. The course modules are organized around the natural course of the disease, covering aspects related to primary prevention through vaccination against HPV and the detection and treatment of precancerous lesions. The course also addresses aspects of the diagnosis and treatment of invasive cervical cancer, as well as the provision of palliative care.Furthermore, the course addresses community mobilization for the use of preventive cancer services and provides information on organizing preventive services, and on organizing programs for cervical cancer control. The course is currently available in both English and Spanish.


This is a free course aimed at health sector workers directly involved in the management of cervical cancer. It is especially useful for medical and nursing teams working at the primary care level and for students in programs such as medicine, nursing, and public health. Managers of health programs can also benefit from this course.


For all strategies, the relative ordering of test technologies in reducing cervical cancer incidence and mortality was VIA (least effective); VIA/VILI; careHPV@1.0 pg/ml and careHPV@0.5 pg/ml (most effective). For once-lifetime strategies, maximum effectiveness was achieved if screening occurred between 35-50 years. Assuming a participation rate of 70%, once-lifetime screening at age 35 years would reduce cancer mortality by 8% (for VIA) to 12% (for careHPV@0.5) over the long term, with a CER of US$557 (for VIA) to $959 (for careHPV@1.0) per life year saved (LYS) compared to no intervention; referenced to a 2008 GDP per capita in Shanxi Province of $2,975. Correspondingly, regular screening with an age-standardised participation rate of 62% (which has been shown to be achievable in this setting) would reduce cervical cancer mortality by 19-28% (for 10-yearly screening) to 43-54% (using IARC-recommended intervals), with corresponding CERs ranging from $665 (for 10-yearly VIA) to $2,269 (for IARC-recommended intervals using careHPV@1.0) per LYS.


Cancer of the uterine cervix is associated with a substantial burden of disease and is a significant cause of death amongst women in the People's Republic of China. The number of cases of cervical cancer in China is estimated to have increased by 14% over the period from 2000 to 2005 [1]. In the absence of substantial intervention, the number of new cases is projected to further increase over the next several decades, due to population ageing [2]. There may be considerable heterogeneity in rates of cervical cancer within China, and the evidence is consistent with a higher burden of disease in some rural areas [2].


Various approaches to screening in rural China and other low resource settings have been considered. Given the critical nature of the role of human papillomavirus (HPV) infection in the causation of cervical cancer, a potential screening strategy is to perform primary testing for infection with high risk types of HPV. However, to date, the higher cost of HPV DNA testing has precluded its use as part of large scale screening programs in low resource settings. More recently, efforts have been made to develop a lower cost rapid throughput test. CareHPV is a new technology which has been developed via a public/private partnership between Qiagen Inc (Gaithersburg, MD) and PATH (Seattle, WA, USA), which has been shown to have high sensitivity for detection of cervical intraepithelial neoplasia grade 2 and above (CIN2+) in rural China [3]. The only realistic currently available screening alternatives to careHPV in this setting are visual inspection techniques; cytology-based approaches are difficult to implement due to the need for high levels of quality assurance and ongoing training, and HPV screening with technologies used in developed countries, such as Hybrid Capture 2 (HC2, Qiagen, Gaithersberg, MD), is likely to be too expensive to implement on a large scale. HPV vaccination offers an additional cervical cancer prevention strategy, but if it should become available and affordable in rural China in the near future, optimal outcomes will be achieved if vaccination of younger cohorts is implemented in conjunction with screening of older cohorts [4].


The objective of the current study was to perform a comprehensive assessment of the cost-effectiveness and impact on cancer incidence and mortality of various screening strategies, focusing on assessing the relative benefits of careHPV and visual inspection screening in rural China. We utilised detailed epidemiological data on sexual behaviour, HPV infections, test accuracy and costs in rural Shanxi province [3, 5, 6] to construct a mathematical model of HPV infection, cervical intraepithelial neoplasia (CIN), and cervical screening. We simulated screening with careHPV at 0.5 pg/ml and 1.0 pg/ml thresholds, and compared the findings to those for screening with visual inspection using acetic acid, when used alone (VIA) or in combination with Lugol's iodine (VIA/VILI). For each screening test, a number of different strategies were considered, including once- or twice-lifetime mobile screening strategies which would screen women aged 35 and/or 45 years; or regular program-based screening among women aged 30-59 years, at 10-yearly, 5-yearly or International Agency for Research on Cancer (IARC)-recommended intervals (for cytology) of every 3 years in women aged 25-49 years and every 5 years in women aged 50-64 years [7]. We calculated the cost-effectiveness of each of these potential strategies, in order to provide data for health care decision makers on potentially feasible screening options using currently available technology.


We adapted and updated a previously developed Markov model of CIN and invasive cervical cancer natural history [10], which was informed by published data on the probability of CIN3 progressing to invasive cervical cancer [11]. We used a standard assumption in cervical cancer evaluations, that CIN natural history (but not HPV infection) is similar in different populations worldwide. The parameters for CIN progression and regression (but not for HPV infection rates) were based on a review of the literature [12] and were then more precisely estimated, as previously described, using data from a well-characterised screened population (Australia) after accounting for detailed screening behaviour and screening test accuracy [12]. For rural China, stage-specific invasive cancer survival was based on average survival rates from the International Federation of Gynecology and Obstetrics (FIGO) [13]. In order to calculate age-standardised cancer incidence and mortality rates, we applied the world standard population according to Ahmad et al [14]. Because comprehensive local data on cervical cancer incidence and mortality were not available, we assessed the predicted age-specific cancer incidence in relation to the average value for 24 less developed countries using data from IARC's Cancer Incidence in Five Continents [15].


Shanxi province is divided into 119 counties incorporating over 1000 townships or communities, with villages being the lowest administrative units within each community. Villages are usually equipped with a small health clinic, whereas large hospitals are generally located in the county-level cities. The screening and management pathways considered in this study included: mobile screening conducted by screening teams travelling to villages, visiting each village on average either once or twice in the lifetime of the target population; versus programs for repeated recall for screening at centralised county hospitals, which would potentially occur at 10-yearly, 5-yearly or IARC-recommended intervals. These viable and locally acceptable methods of screening organisation were determined in consultation with local clinicians and CICAMS epidemiologists (Personal Communication, Professor You-Lin Qiao). Screening participation assumptions were informed by unpublished data from a government-sponsored VIA/VILI screening demonstration project in 3,492 women aged 30-59 years who were screened using VIA/VILI in Xiangyuan, Shanxi Province in 2006 (Personal Communication, Professor You-Lin Qiao). Based on these data, we assumed an overall participation rate of 71% for one screening round implemented by a mobile service. To take into account the reduced screening coverage reported at older ages in the demonstration project, for regular program-based screening conducted at county hospitals we assumed age-specific participation patterns, with an overall age-standardised participation rate of 62% in screened age groups (Table 1).


Figure 1 depicts the structure of the screening, diagnosis and treatment pathways used for each of the test modalities; model parameters for screening and diagnosis are summarised in Tables 1 and 2. For VIA, test positives were assumed to have immediate colposcopy, and therefore no women were lost to diagnostic follow-up; for combined VIA/VILI strategies, VIA positives had immediate colposcopy whereas VIA negatives underwent VILI testing. However, VILI-positive women could not have immediate colposcopy since the use of Lugol's iodine precludes full colposcopic examination with acetic acid; in this case colposcopy after positive VILI was assumed to be performed on the next day with some women (10%) lost to follow-up. An age-specific probability of having unsatisfactory visual inspection results (in which the original squamocolumnar junction was not fully visible) was incorporated using data from a previous study [5]. A proportion (10%) of women with unsatisfactory but negative VIA or VILI test results were assumed to undergo endocervical curettage (ECC) on the same day (Figure 1). We also incorporated an age-specific unsatisfactory rate for colposcopy, which was based on local data [5, 16]. 041b061a72


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