Fabio Russomano

Systematic review of economic evaluations of triage tests for women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL)

Abstract Objectives To synthesize the results of cost-effectiveness studies of different triage tests in comparison to repeat cytology for women with atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) results. Methods Electronic databases (Medline/PubMed, Lilacs, Embase, The Cochrane Library, Scopus, Web of Science, Scielo, The NHS Economic Evaluation Database, Econlit, and CEA Registry) were searched for cost-effectiveness or cost-utility publications. Per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent reviewers selected eligible publications based on the selection criteria and performed data extraction. Methodological quality was assessed using the Quality of Health Economic Studies tool. Results Five cost-effectiveness analyses were included comparing HPV testing, immediate colposcopy, and liquid-based cytology with HPV testing reflex to repeat cytology. The main outcome adopted was cervical intraepithelial neoplasia level 2 or higher (CIN2+) cases detected. In pairwise comparisons, HPV testing was more frequently observed as the most cost-effective strategy. Incremental cost-effectiveness ratios were very sensitive to costs of test kit variation and accuracy estimates with some sensitivity analysis scenarios showing immediate colposcopy more cost-effective than HPV testing depending on the tests’ unitary costs and effectiveness. Conclusions This systematic review of economic evidence corroborates clinical evidence showing cytology is the least effective, although less costly, triage strategy. Cytology-based triage programs need to be updated to offer timely treatment to women diagnosed with ASC-US/LSIL and better resource allocation.

Accuracy of endocervical cytological tests in diagnosing preinvasive lesions of the cervical canal in patients with type 3 transformation zone: a retrospective observational study

Cervical cancer screening in Brazil is done using Pap smears. Women who are most likely to have a preinvasive lesion or cervical cancer are immediately referred for colposcopy. The aim of this study was to evaluate the diagnostic performance of endocervical cytological tests in diagnosing preinvasive cervical lesions in women with initial high-grade squamous intraepithelial lesions (HSIL), or atypical squamous cells in which high-grade lesions could not be ruled out (ASC-H), or atypical glandular cells (AGC), and whose colposcopy did not show any abnormalities, with no fully visible transformation zone (types 2 and 3). Retrospective observational study conducted in Rio de Janeiro, Brazil. Data from women who came to the cervical pathology outpatient clinic between January 2012 and April 2017 were analyzed. The results from endocervical cytological tests were compared with the final diagnosis, which was obtained through examination of a surgical specimen or, among women who did not undergo an excisional procedure, after cytological and colposcopic follow-up for two years. We included 78 women. The sensitivity of endocervical cytological tests was 72.7%; specificity 98.5%; positive and negative predictive values 88.9% and 95.6%, respectively; and positive and negative likelihood ratios 48.7 and 0.28. Endocervical cytological tests are simple, inexpensive and noninvasive, and form a reliable method for determining management among patients with HSIL, ASC-H and AGC cytological findings and negative colposcopic findings without visualization of the squamocolumnar junction.

Negative histology in cervical specimens obtained with the "see and treat" method among women at a referral center in Rio de Janeiro, Brazil: a cross-sectional study

Abstract Background According to the Brazilian Guidelines on Cervical Cancer Screening, women with cytopathologic diagnosis of high-grade intraepithelial lesion, abnormal colposcopic findings, fully visible squamocolumnar junction and age 25 years or older should be treated at the first visit (“see and treat—S&T”). The main limitation to this approach is the risk of overtreatment, identified by histology without preinvasive lesion. The objectives of this study were to identify the overtreatment rate in women undergoing S&T in cervical cancer prevention at a referral center with extensive experience with the method and to detect possible factors associated with this rate. Methods This was a cross-sectional study that analyzed records from a database with 616 women submitted to S&T from 1996 to 2017. Negative histology was defined as the following histopathologic results: human papillomavirus without cervical intraepithelial neoplasia (CIN), inflammatory, low-grade squamous intraepithelial lesion, and CIN 1. Results Of the 616 women, there were 52 (8.44%, 95%CI 6.25–10.64%) with a histopathologic report without preinvasive cervical lesion. No statistical association was found between this outcome and age or a significant downward trend over time. Conclusion The overtreatment rate in this study can be considered low and consistent with the acceptable rates reported in the literature, reinforcing the prevailing Brazilian guideline, in which the benefits of immediate treatment outweigh the risk of losses following biopsy.

Frequency of post-treatment disease after excisional procedure in stage IA1 squamous cervical carcinoma – a case series

Early stages of cervical cancer in young women need conservative treatments. Electrosurgical therapies (LLETZ, LEEP, SWETZ, NETZ) have been recommended for these women. However, there are recommendations to perform a second excision when the specimen margins are not free of disease. This can lead to some important complications. This article aims to verify the frequency of residual invasive or microinvasive disease after the excisional procedure in women with IA1CC. Data on women with IA1CC diagnosed between 1990 and 2022, were retrieved from medical records. Post-treatment disease was detected during a second surgical procedure or postoperative follow-up. Among the 69 included women, three (4.3 percent; CI95 percent 0-9.2) had residual microinvasive lesions, while none showed invasive disease during a second procedure or follow-up. Only the age of 37 years or more was significantly related to the presence of preinvasive or microinvasive residual lesions. Nearly 80 percent of the women who underwent a second procedure showed no residual lesions. The absence of invasive disease in a second procedure or during the follow-up of these women and the large proportion of women with no residual lesion questions the need for a new surgical procedure even when the surgical margins of the initial specimen are involved.