Xuelian Zhao

Impact of government-organized screening programs on the economic burden of cervical cancer across five disease courses: a multistage regression and mediation analysis

Objective: To evaluate the impact of government-organized screening on the economic burden among patients with cervical cancer and precancerous lesions, and explore mediating pathways across diagnosis, initial treatment, radiotherapy/chemotherapy, follow-up, and recurrence/progression/metastasis. Methods: A multicentre, nationwide survey across 5 disease courses was conducted from 26 hospitals in China. Multivariable regression and structural equation modeling were used to assess the effects of government-organized screening on economic burden by comparing government-organized screening with workplace check-up, self-paid check-up, and symptom-based detection. Results: Workplace check-up, self-paid check-up, and symptom-based detection were associated with progressively higher costs across diagnosis [β: 1.10, 95% confidence interval (CI): 0.54–1.67; β: 1.46, 95% CI: 1.00–1.92; and β: 1.68, 95% CI: 1.25–2.11, respectively], initial treatment (β: 0.36, 95% CI: 0.18–0.55; β: 0.51, 95% CI: 0.35–0.66; and β: 0.56, 95% CI: 0.42–0.70, respectively), and follow-up (β: 0.63, 95% CI: 0.38–0.88; β: 0.83, 95% CI: 0.61–1.04; and β: 0.85, 95% CI: 0.65–1.06, respectively) compared to government-organized screening (all P < 0.05). Earlier clinical staging and greater use of lower-level hospitals mediated 44.74%–54.97% of cost differences in diagnosis, 73.27%–85.04% in initial treatment, and 30.38%–54.73% in follow-up. Fifteen percent of the cost differences during initial treatment were related to lower overtreatment for precancerous lesions. Conclusions: Government-led cervical cancer screening was associated with lower economic burden with pathways involving earlier-stage diagnosis, reduced overtreatment, and decreased reliance on higher-level hospitals, suggesting potential clinical benefits, efficient resource use, and improved equity in cancer care.

Efficacy and immunogenicity of AS04‐HPV‐16/18 vaccine in females with existing cervical HR‐HPV infection at first vaccination: A pooled analysis of four large clinical trials worldwide

AbstractFemales with existing high‐risk HPV (HR‐HPV) infections remain at risk of subsequent multiple or recurrent infections, on which benefit from HPV vaccines was under‐reported. We pooled individual‐level data from four large‐scale, RCTs of AS04‐HPV‐16/18 vaccine to evaluate efficacy and immunogenicity in females DNA‐positive to any HR‐HPV types at first vaccination. Females receiving the AS04‐HPV‐16/18 vaccine in the original RCTs constituted the vaccine group in the present study, while those unvaccinated served as the control group. Vaccine efficacy (VE) against new infections and associated cervical intraepithelial neoplasia (CIN) 2+ in females DNA‐negative to the considered HR‐HPV type but positive to any other HR‐HPV types, VE against reinfections in females DNA‐positive to the considered HR‐HPV type but cleared naturally during later follow‐up, and levels of anti‐HPV‐16/18 IgG were assessed. Our final analyses included 5137 females (vaccine group = 2532, control group = 2605). The median follow‐up time was 47.88 months (IQR: 45.72‐50.04). For the prevention of precancerous lesions related to the non‐infected HR‐HPV types at baseline, VE against HPV‐16/18 related CIN 2+ was 82.70% (95% CI: 63.70‐93.00%). For the prevention of reinfections related to the infected HR‐HPV types following natural clearance, VE against HPV‐16/18 12MPI was non‐significant (p > .05), albeit robust immunity persisted for at least 48 months. Females with existing HR‐HPV infections at first vaccination still benefit from vaccination in preventing precancers related to the non‐infected types at baseline. VE against reinfections related to the infected types following natural clearance remains to be further investigated.

Implementation of visual inspection with acetic acid and Lugol's iodine for cervical cancer screening in rural China

AbstractObjectiveTo address the value of visual inspection where HPV‐based screening is not yet available, we evaluated the real‐world effectiveness of visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI) as a primary screening method for cervical cancer in rural China.MethodsA total of 206 133 women aged 30–59 years received two rounds of VIA/VILI screening for cervical cancer in 2006–2010. Women with positive screening results underwent colposcopy and direct biopsy, and were treated if cervical intraepithelial neoplasia grade 2 or worse (CIN2+) was diagnosed. Clinical effectiveness of VIA/VILI was evaluated by process and outcome measures.ResultsThe VIA/VILI positivity rate, biopsy rate and detection rate of CIN2+ in the second round were significantly lower than in the first round. The 2‐year cumulative detection rate of CIN2+ varied from 0.53% to 0.90% among the four cohorts initiated in 2006, 2007, 2008, and 2009. The first round of screening detected 60%–83% of CIN2, 70%–86% of CIN3, and 88%–100% of cervical cancer. Over 92% of CIN2+ were found at the early stage.ConclusionMultiple rounds of visual inspection with continuous training and quality assurance could act as a temporary substitutional screening method for cervical cancer in resource‐restricted settings.