Ania Wisniak

Autoprélèvement HPV et dépistage du cancer du col utérin

Carcinogenic human papillomavirus (HPV) infections cause the majority of cervical cancers (CC). While vaccination represents primary prevention, screening remains essential. HPV testing, more sensitive than cytology, is recommended as the primary method in some European countries. Among women aged ≥ 30 years, HPV selfsampling improves access to screening and can increase coverage of underscreened populations by up to 2.5-fold; several countries have adopted this approach. In Switzerland, where screening is opportunistic and only cytology is reimbursed, 30 % of women remain under-or unscreened. Introducing HPV self-sampling for underscreened women could contribute to the goals set by the World Health Organization. This review provides an overview of the situation in Switzerland and Europe regarding CC screening.

Fertility and Miscarriage Incidence After Cervical Intraepithelial Neoplasia Treatment by Thermal Ablation: A Cohort Study

ABSTRACTObjectiveTo assess the impact of thermal ablation (TA) for the treatment of cervical dysplasia on fertility and pregnancy outcomes among women screened for cervical cancer in Cameroon.DesignRetrospective cohort study.SettingDschang health district, Cameroon.PopulationParticipants aged 30–45 years from two screening trials conducted between 2015 and 2020 in Dschang District Hospital.MethodsParticipants were primarily screened for human papillomavirus infection, triaged by visual inspection and treated by TA if needed. Between October 2021 and March 2022, interviews on subsequent fertility were conducted with participants treated by TA and a control group of untreated women.Main Outcome MeasuresPregnancy and miscarriage after screening/treatment.ResultsA total of 760 participants (219 treated and 541 untreated) completed the survey, with a mean follow‐up time of 1297 days. Sixty‐two women (28.3%) treated by TA reported a pregnancy postscreening versus 165 (30.5%) in the control group (p = 0.550). Adjusted for potential confounders, the hazard ratio of pregnancy for treated compared with untreated women was 0.82 (0.54–1.24, p = 0.350). Among women reporting pregnancies with a known outcome and which were not voluntarily terminated, 18 (35.3%) treated participants had a miscarriage versus 31 (21.4%) in the control group (p = 0.048). In the adjusted model, no association remained between TA and miscarriage (1.04, 0.39–2.78, p = 0.935).ConclusionsIn our study population, TA did not significantly impact fertility nor miscarriage risk. Our results support the widespread use of TA as a treatment of choice for precancerous cervical lesions in low‐income settings.

Utility of extended HPV genotyping for the triage of self-sampled HPV-positive women in a screen-and-treat strategy for cervical cancer prevention in Cameroon: a prospective study of diagnostic accuracy

Objective To explore the utility of extended Human Papillomavirus (HPV) genotyping to detect cervical intraepithelial neoplasia grade 2 or more (CIN2+) in a ‘screen-and-treat’ strategy for HPV-positive women in low-resource settings. Design Prospective study of diagnostic accuracy. Setting The study took place in West Cameroon between September 2018 and March 2020. Participants 2014 women were recruited. Asymptomatic, non-pregnant women aged 30–49 years without history of CIN treatment, anogenital cancer or hysterectomy were eligible. Interventions Participants performed self-sampling for HPV testing with GeneXpert followed by visual inspection with acetic acid and Lugol’s iodine (VIA) triage before treatment if required. Main outcome measures Liquid-based cytology, biopsies and endocervical brushing were performed in HPV-positive women as quality control. We assessed the detection rate of CIN2+ by HPV genotyping (two pools of genotypes obtained from the Xpert system, pool_1 (HPV 16, 18, 45) and pool_2 (HPV 16, 18, 45, 31, 33, 35, 52, 58)), VIA and cytology. Results 382 (18.2%) women were HPV-positive among which 11.5% (n=44) were CIN2+. Of those 44 participants, 41 were triaged positive by extended genotyping, versus 35 by VIA and 33 by cytology. Overall, triage positivity was of 68.4% for extended genotyping, 59.3% for VIA and 14.8% for cytology, with false positive rates of 83.4%, 84.1% and 37.7%, respectively. Extended genotyping had a higher sensitivity for CIN2+ detection (93.2%, CI: 81.3 to 98.6) than VIA (79.5%, CI: 64.7 to 90.2, p=0.034) and cytology (75.0%, CI: 59.7 to 86.8, p=0.005). No significant difference was observed in the overtreatment rate in triaged women by extended genotyping or VIA (9.9%, CI: 8.6 to 11.3, and 8.8%, CI: 7.7 to 10.1), with a ratio of 6.0 and 6.3 women treated per CIN2+ diagnosed. Conclusion Triage of HPV-positive women with extended HPV genotyping improves CIN2+ detection compared with VIA with a minor loss of specificity and could be used to optimize the management of HPV-positive women. Trial registration number NCT03757299 .

ABCD criteria to improve visual inspection with acetic acid (VIA) triage in HPV-positive women: a prospective study of diagnostic accuracy

Objectives A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting. Design Prospective study of diagnostic accuracy. Setting Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon. Participants Asymptomatic non-pregnant women aged 30–49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35–45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial. Interventions HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards). Primary outcome measure Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values. Results ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day. Conclusions ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context. Trial registration number NCT03757299 .

Promoting Comprehensive Cervical Cancer Prevention and Better Women Health in Cameroon

In sub-Saharan Africa, cervical cancer is the leading cause of cancer death among women because of the difficulty in implementing screening programs. The main obstacles in these countries are poverty, lack of healthcare infrastructures and trained practitioners. With the availability of new technologies, researchers are looking for new strategies adapted to low- and middle-income countries to identify cervical precancerous lesions. Current evidence shows that Human Papilloma Virus (HPV) testing is more effective than cytology (Pap smear) for cervical cancer screening in resource-limited settings. Indeed, the GeneXpert® HPV test offers the opportunity to prevent cervical cancer (CC) in a single visit: rapid detection of high-risk HPV (HPV) infection followed by same day treatment of HPV-positive women during the same visit (screen-and-treat approach). However only a small proportion of HPV-positive women will develop cervical (pre)cancer, making it important to select those to treat. This triage can be achieved by colposcopy, cytology and visual inspection after application of acetic acid (VIA). Though VIA is the triage test recommended by WHO for resource-limited countries, it has not yet been widely assessed in sub-Saharan Africa (SSA). The main objective of the investigators is to assess the performance of HPV-test followed by Visual Inspection after application of Acetic acid and Lugol's iodine VIA/VILI to detect cervical precancerous lesions in a screen-and-treat strategy in Cameroon (sub-Saharan Africa) where there is no cervical cancer-screening program. The investigators organized a successful free screening campaign in Cameroon in 2015 that allowed to identify the expectations of women and their eagerness to benefit from prevention of gynecological cancers and sexually transmitted diseases.