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Screening and Treatment

There’s an App for That: Smartphones and Cervical Cancer Screening in Africa

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Canadian and Tanzanian researchers are developing smartphone technology to bring cervical cancer screening to remote areas.

Since its introduction in the 1950s, Pap tests have significantly reduced rates of cervical cancer in countries with broad screening programs. The tests are difficult to do in the developing world, though, due to a lack of labs and pathologists to read and process the tests. Another hurdle is that many women in poor countries simply don’t live near medical facilities, so testing and, especially, follow-up exams are seldom practical. Over 80% of cervical cancers occur in the developing world, where the disease remains one of the leading causes of cancer-related deaths among women, so a simple, effective “on the spot” test is sorely needed. Enter the smartphones and a bit of ingenuity.

The Kilimanjaro Cervical Cancer Screening Project in Tanzania, led by principal investigator Karen Yeates, is utilizing smartphones and patient tracking apps to screen women for cervical cancer. Non-physician health workers use the cameras on their phones to take a snapshot of the cervix (known as cervicography) which is transmitted to a health center and reviewed by an expert. If cancerous areas are present, treatment instructions are transmitted back to the health care worker. The entire review process is done in minutes, and the quick diagnosis and treatment is a boon to women in remote areas for whom “come into the office in a week or two” isn’t practical.

The project is being funded as one of Canada’s Grand Challenges, a government-sponsored program that supports innovative “bold ideas” in science, technology, and business. For more on the project go to http://www.grandchallenges.ca/grantee-stars/0109-01/.

 

Counter-Intuitive: Will Treatment Focus on Healthy Cervical Cells Rather Than Tumors?

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In a Zen-like twist, findings by Irish researchers suggest new approaches to cervical cancer treatment might involve the healthy tissue around a tumor, rather than the malignant area itself.

The star of this show is the retinoblastoma protein (referred to as Rb) which, when depleted in healthy cells, encourages nearby cancer cells to invade, explain the researchers from Queen’s University in Belfast. So the drill is simple: when Rb is feisty and active, cancer cells lurking in the neighborhood are less inclined to “come on over.” When Rb is depleted, the cancer cells get a message that it’s ok to move in to the healthy areas. Since nature makes the cancer aggressive anyway, not much encouragement is needed.

Writing in the abstract of their article, the Irish team leading this research said “Our data identify that stromal fibroblasts can alter the invasive behavior of the epithelium.” In plain English: if we can figure out how to keep Rb up and running at full speed, cancer cells may be less likely to invade other, unaffected areas in the vicinity.

The Irish team’s research focused on cervical and head/neck cancers, both prime areas of HPV-related diseases. The potential impact these findings may have with research into treating cancers in both sites (and elsewhere) is intriguing: HPV produces a sneaky protein of its own that binds to Rb and essentially degrades it, so a better understanding of that relationship might be key to keeping tumors from spreading. A summary of the study can be found here.

 

ACOG Updates Cervical Cancer Screening Guidelines

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Updated guidelines issues by the American College of Obstetricians and Gynecologists (ACOG) say most women should be screened for cervical cancer once every three to five years.

ACOG’s guidelines essentially mirror those published earlier in 2012 by the American Cancer Society (ACS), the U.S. Preventive Services Task Force (USPSTF), and other organizations. Highlights include: • Cervical cancer screening with Pap tests should begin at age 21, regardless of sexual history

• Pap testing should not be done for most women more often than every three years, a big change from the traditional "annual Pap" regimen many women and doctors traditionally used. Women are still recommended to go for yearly “well woman” visits and, of course, those with abnormal Paps will be tested more often

• Rather than using a Pap test alone, HPV/Pap co-testing is now the preferred method of screening women age 30 and over. Such co-testing should only occur once every five years with women who have normal test results

• HPV testing should not be done in women under age 30 other than as follow-up to unclear Pap test results

• Cervical cancer screening can end for most women at age 65, provided she has no history of cervical pre-cancer or cancer, and has had at least three consecutive, normal Pap tests (or two normal HPV tests) within the last 10 years. Women at greater risk for cervical cancer (e.g., those with a history of cervical pre-cancer or cancer and those who are HIV-positive or otherwise have weakened immune systems) may require screening more frequently

The reason for moving away from the annual Pap is evidence shows little gain in testing more often, but potential harm of “over screening” such as follow-up exams (like colposcopy/biopsy) and treatment to the cervix, especially with women of child-bearing age.

The new guidelines are found in ACOG Practice Bulletin Number 131, Screening for Cervical Cancer, which will be published in the November issue of Obstetrics & Gynecology. Read the announcement on ACOG’s website.

 

Updated Cervical Cancer Screening Guidelines

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On March 14 the American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) released updated guidelines for cervical cancer screening. Highlights include:

  • Cervical cancer screening with Pap tests should begin at age 21, regardless of sexual history. Previous guidelines called for screening to begin within three years of a female becoming sexually active.
  • Pap testing should not be done more often than every three years, a big change from the traditional "annual Pap" regimen many women and doctors traditionally used. -HPV testing should not be done in women under age 30 other than as follow-up to unclear Pap test results.
  • HPV testing is appropriate (ACS says preferred), in conjunction with a Pap, in women age 30 and over. Such co-testing should only occur once every five years.
  • Cervical cancer screening can end for most women at age 65, provided she has had at least three consecutive, normal Pap tests (or two normal HPV tests) within the last 10 years.

Read more at Cancer.org. These updated recommendations bring ACS and USPSTF essentially in line with guidance issued by the American College of Gynecologists (ACOG), the other leading professional organization that influences cervical cancer screening practice.

The reason for ditching the annual Pap is evidence shows little gain in testing more often, but potential harm of “over screening” such as follow-up exams (like colposcopy/biopsy) and treatment to the cervix, especially with women of child-bearing age.

 

Do it Yourself? Another Look at Self-Sampling and HPV Testing

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A study from China finds the accuracy of HPV tests done with patient-collected samples may be good enough to offer a complement to existing cervical cancer screening programs into low-resource areas.

Since the introduction of the Pap test in the mid-20th century, cervical cancer rates have plummeted in nations that have widespread screening programs. In the developing world, however, where medical services are often lacking, cervical cancer remains a huge public health issue. More than 80% of all cases of the disease occur in poverty-stricken areas of the globe, largely due to a lack screening programs. One approach to reaching these women may be a more private, convenient “do it yourself” approach where patients literally are given a self-sampling device with instructions on correct insertion, cell collection, and storage/transport.

In a study done with more than 13,000 women enrolled in five cervical cancer screening studies throughout China, researchers looked at how well HPV tests done with self-collected samples compare to other methods of screening for the disease: health care provider-collected samples, visual inspection with acid (VIA, where acetic acid is applied to the cervix making it easier to see any lesions), and liquid-based Pap tests (LBP, cells are collected as with a conventional Pap but instead of being affixed to a glass slide, the cells are put in a liquid-suspension solution in a vial). The investigators compared the sensitivity (avoiding a false negative test result) and specificity (avoiding a false positive) of each method in detecting moderate to severe cervical diseases (cervical intraepithelial neoplasia, or CIN 2 and CIN 3). China was a good venue for such research, given the country lacks a broad screening program for cervical cancer yet bears a large burden of the disease.

How did self-sampling stack up against other means of cervical cancer screening? In detecting CIN 2+, self-collected samples had a sensitivity of 86.2%, considerably better than that of VIA (50.3%) and LBC (80.7%) but not as well as those collected by a health care provider (97.0%). The specificity of self-collection in detecting CIN2 + was 80.7%, comparable to provider-collected samples (82.7%) and lower than both VIA (87.4%) and LBC (94.0%).

With CIN 3+, self-collection’s sensitivity was 86.1%, sharply superior to VIA (55.7%), similar to LBC (89.0%), and lower than provider-collected samples (97.8%). Specificity with self-collection in finding CIN3 + was 79.5%, on par with samples taken by providers (81.3%) but lower than VIA (86.9%) and LBC (92.8%).

Reference:
Fang-Hui Zhao, Adam K. Lewkowitz, Feng Chen, Margaret J. Lin, Shang-Ying Hu, Xun Zhang, Qin-Jing Pan, Jun-Fei Ma, Mayineur Niyazi, Chang-Qing Li, Shu-Min Li, Jennifer S. Smith, Jerome L. Belinson, You-Lin Qiao, Philip E. Castle. Pooled Analysis of a Self-Sampling HPV DNA Test as a Cervical Cancer Primary Screening Method. J Natl Cancer Inst 2012;104:1–11