Anna Modest

Comparative analysis of adjuvant treatment outcomes in stage III endometrial cancer: overall survival, recurrence-free survival, site of primary recurrence, and toxicity

Adjuvant treatment for stage III endometrial cancer remains controversial due to varying results from large randomized studies. Our objectives were to assess differences in (1) recurrence-free survival and overall survival, (2) initial recurrence site, and (3) acute and long-term toxicities in patients receiving chemotherapy vs chemoradiation as initial adjuvant treatment. All stage III endometrial cancer patients treated at our institution from 2010 to 2021 were included. Treatment groups were defined as "chemo" if treated with upfront chemotherapy with or without subsequent radiation or "concurrent" if treated with chemoradiation with or without subsequent chemotherapy. Data were collected through retrospective chart review. Univariate analyses were performed using the Mann-Whitney U test, Fisher exact test, and log-rank test. Multivariate analysis was conducted using Cox proportional hazards and generalized linear regression models. A total of 156 patients were eligible for analysis. After adjusting for stage and histology, there was no difference in 5-year recurrence-free survival (HR 0.5, CI 0.22 to 1.11) with the chemotherapy group as reference. However, overall survival was improved in the concurrent group (HR 0.24 CI 0.06 to 0.90). When restricting the analysis to patients with endometrioid histology, overall survival was significantly improved in the concurrent group (HR 0.11, CI 0.16 to 0.73). In the full cohort, pelvic or para-aortic nodal recurrence (p = .01) and distant recurrence (p < .01) were significantly more likely in the chemotherapy group. There were no significant differences in high-grade toxicities. Patients with stage III endometrial cancer who received upfront concurrent treatment had improved overall survival compared with those who received upfront chemotherapy, without significant differences in high-grade toxicities. These findings should be considered in the design of future clinical trials.

Short-term costs and cost-efficiency of HPV triage strategies in a high HIV-prevalence setting: Evidence from Botswana

Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa and is more severe in high HIV-burdened countries due to persistent high-risk human papillomavirus (hrHPV). In 2021, the World Health Organization recommended primary hrHPV testing for cervical cancer screening; however, optimal triage strategies following positive hrHPV tests remain unclear. We conducted a prospective cost analysis of triage methods for positive hrHPV results among women living with and without HIV in Gaborone, Botswana. We used a micro-costing approach from the perspective of the healthcare provider. The main outcomes were the implementation costs associated with three triage strategies following hrHPV testing: 8-type HPV genotype restriction, visual inspection with acetic acid (VIA), and colposcopy. We also compared the strategies by measuring the change in costs divided by the change in number of true cases of cervical intraepithelial neoplasia (CIN) 2 or worse (CIN2+) identified, based on the results of a prospective cohort study. Results indicated that the 8-type HPV genotype restriction strategy was the most cost-efficient, requiring no additional costs beyond hrHPV testing and identifying the highest number of true CIN2 + cases. VIA and colposcopy triage identified fewer true cases of CIN2+ and incurred additional costs, with colposcopy being the most expensive. Results were consistent in women with and without HIV. Sensitivity analysis highlighted personnel and hrHPV test kit cartridge costs as significant drivers of overall costs. Post-hoc analysis incorporating average treatment costs for precancer demonstrated that genotyping remained dominant at lower treatment costs but became less favorable as treatment costs increased. We found that 8-type genotype restriction was optimal compared to hrHPV screening combined with VIA or colposcopy. Cost estimates can inform future studies that examine the long-term costs and health outcomes of HPV-based two-stage screening algorithms.