JCO Global Oncology

Changes in HIV-Related Cervical Cancer Over a Decade in Côte d'Ivoire

PURPOSE Major improvements have occurred in access to invasive cervical cancer (ICC) screening in HIV-infected women over the past decade in sub-Saharan Africa. However, there is limited information on changes in the burden of HIV-related ICC at a population level. Our objective was to compare HIV-related ICC over a decade and document factors associated with HIV infection in women with ICC in Côte d'Ivoire. METHODS A repeated cross-sectional study was conducted in referral hospitals of Abidjan, Côte d'Ivoire, through the 2009-2011 and 2018-2020 periods. Women diagnosed with ICC were systematically tested for HIV. Demographics, ICC risk factors, cancer stage (International Federation of Gynecology and Obstetrics), and HIV characteristics were collected through questionnaires. Characteristics of HIV-related ICC were compared between the periods, and factors associated with HIV in women diagnosed with ICC in 2018-2020 were documented through a multivariable logistic model. RESULTS During the 2009-2011 and 2018-2020 periods, 147 and 297 women with ICC were diagnosed with estimated HIV prevalence of 24.5% and 21.9% ( P = .53), respectively. In HIV-infected women, access to antiretroviral treatment increased from 2.8% to 73.8% ( P < 10−4) and median CD4 cell count from 285 (IQR, 250-441) to 492 (IQR, 377-833) cells/mm3 ( P = .03). In women diagnosed with ICC during the 2018-2020 period, HIV infection was associated with a less advanced clinical stage (International Federation of Gynecology and Obstetrics I or II stage) (adjusted OR, 2.2 [95% CI, 1.1 to 4.4]) and with ICC diagnosis through a systematic screening (adjusted OR, 10.5 [95% CI, 2.5 to 45.5]). CONCLUSION Despite a persistently high proportion of HIV-related ICC over time in Côte d'Ivoire, HIV was associated with less advanced clinical stage at ICC diagnosis. Recent improvements in ICC screening services across HIV clinics might explain this association and support their implementation across non-HIV health facilities.

Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting

Delays in care for patients with cervical cancer in Botswana can be benchmarked using a multidisciplinary clinic model.

Genetic Counseling, Testing, and Management of HBOC in India: An Expert Consensus Document from Indian Society of Medical and Pediatric Oncology

PURPOSE Hereditary breast and ovarian cancer (HBOC) syndrome is primarily characterized by mutations in the BRCA1/2 genes. There are several barriers to the implementation of genetic testing and counseling in India that may affect clinical decisions. These consensus recommendations were therefore convened as a collaborative effort to improve testing and management of HBOC in India. DESIGN Recommendations were developed by a multidisciplinary group of experts from the Indian Society of Medical and Pediatric Oncology and some invited experts on the basis of graded evidence from the literature and using a formal Delphi process to help reach consensus. PubMed and Google Scholar databases were searched to source relevant articles. RESULTS This consensus statement provides practical insight into identifying patients who should undergo genetic counseling and testing on the basis of assessments of family and ancestry and personal history of HBOC. It discusses the need and significance of genetic counselors and medical professionals who have the necessary expertise in genetic counseling and testing. Recommendations elucidate requirements of pretest counseling, including discussions on genetic variants of uncertain significance and risk reduction options. The group of experts recommended single-site mutation testing in families with a known mutation and next-generation sequencing coupled with multiplex ligation probe amplification for the detection of large genomic rearrangements for unknown mutations. Recommendations for surgical and lifestyle-related risk reduction approaches and management using poly (ADP-ribose) polymerase inhibitors are also detailed. CONCLUSION With rapid strides being made in the field of genetic testing/counseling in India, more oncologists are expected to include genetic testing/counseling as part of their clinical practice. These consensus recommendations are anticipated to help homogenize genetic testing and management of HBOC in India for improved patient care.

Outcomes of Loop Electrosurgical Excision Procedures Performed for Severe Cervical Dysplasia in Botswana

PURPOSE In Botswana, a see-and-treat approach to cervical cancer screening is taken. Our objective was to determine the number of loop electrosurgical excision procedures (LEEPs) performed for cervical intraepithelial neoplasia (CIN) 2/3 in Botswana, and follow-up rates and outcomes, among women with positive cervical margins. METHODS Data (patient age, HIV status, margin status, follow-up, and recurrence) from women who underwent LEEP with histologically confirmed CIN 2/3 between January 2014 and December 2015 were analyzed retrospectively. Histopathologic reports were reviewed at a central laboratory in Gaborone, Botswana. Follow-up and recurrence rates were summarized descriptively and compared according to HIV and margin statuses using chi-squared tests. RESULTS In total, 779 women (median age, 39.2 years) underwent LEEP showing CIN2/3; 638 (81.9%) women had CIN3 and 390 (50.1%) had positive LEEP margins (ectocervical, 186 [47.7%]; endocervical [including with ectocervical], 204 [52.4%]). Margin positivity was not associated with HIV status. Of women with positive endocervical margins followed at ≤1 and >1 year, 9.6% and 48.3%, respectively, had persistent CIN2/3 on repeat LEEP. Forty percent (90 of 204) of women with positive endocervical margins had no re-excision documented. CONCLUSION Most women who underwent LEEP had CIN3 and positive margins. Almost half with positive margins followed at >1 year after initial LEEP had CIN2/3 recurrence warranting further treatment; two thirds were not followed. Resources are needed to improve post-LEEP follow-up for women with margin positivity who require additional ablative/excisional procedures to reduce the cervical cancer burden in Botswana.

Overcoming Logistical Barriers to Conducting Collaborative Clinical Research Between a High-Income Country and a Low- and Middle-Income Country

PURPOSE Building equitable research collaborations between high-income countries (HICs) and low- and middle-income countries (LMICs) requires effective coordination among international ethical review committees, which is often logistically challenging. This case report presents the insights gained when acquiring ethical approval for a cervical cancer research program conducted jointly by the University of Pennsylvania and the University of Botswana. METHODS We conducted a descriptive case study of the Ipabalele project, a 6-year HIC-LMIC partnership involving three complex research protocols that required approvals by multiple distinct ethical bodies. We analyzed various challenges affecting review procedures, timelines, and staffing. We then documented strategies employed in Ipabalele and other global initiatives to strengthen ethical review processes and build research capacity in LMICs. RESULTS In Ipabalele, ethical approvals were initially delayed by 2 years because of fragmented review processes with variable timelines and conflicting recommendations. Innovations to the process included centralizing institutional review board oversight within Botswana, implementing joint virtual meetings among review bodies, enhancing digital infrastructure, and streamlining research staffing and communication. CONCLUSION By providing practical strategies, this study highlights how empowered local leadership, centralized review processes, joint review mechanisms, and intentional capacity building can overcome logistical barriers in multinational ethical review.

Racial Disparities in Endometrial Cancer Incidence and Outcomes in Brazil: Insights From Population-Based Registries

PURPOSE This study aimed to examine trends in the incidence and mortality rates of endometrial cancer (EC) across ethnic groups in Brazil and to analyze the demographic and clinicopathological characteristics associated with these trends. METHODS The incidence of EC was analyzed from 2010 to 2015 using data from Brazilian Population–Based Cancer Registries (PBCRs), including crude rates and annual percentage changes (APCs). Clinical and sociodemographic information from 2000 to 2019 was gathered from Hospital-Based Cancer Registries. Mortality data between 2000 and 2021 were obtained from the National Mortality Information System, allowing for comparisons between White women and Black women. RESULTS From 2010 to 2015, a total of 32,831 new cases of EC were reported across 13 PBCRs, with Black patients accounting for 35.7% of these cases. The median age at diagnosis was 63 years, with Black women diagnosed at a younger age than White women. Black patients experienced a significant increase in incidence rate (APC +6.7% v +3.0%). A greater proportion of Black patients lived without partners (54.0%), had higher rates of alcohol consumption (15%) and smoking (25.8%), and resided in less developed regions (54.6%) with lower education levels (77.5%). From 2000 to 2021, Brazil recorded 72,189 EC-related deaths, showing higher mortality rates among White women (3.8 per 100,000) than Black women (2.4 per 100,000), although the downward trend was steeper among White women (–1.2%) than Black women (–0.6%). CONCLUSION Racial disparities in EC incidence and mortality in Brazil may be closely linked to unfavorable sociodemographic factors faced by Black women. Targeted public health initiatives are critical for improving early detection and access to equitable care for Black women.

Survival in Cervical Cancer and Its Predictors at Ocean Road Cancer Institute From January to December 2012

PURPOSE In Tanzania, cancer of cervix is the most commonly diagnosed cancer and is the leading cause of cancer-related deaths. There are very little data about survival of patients with cervical cancer after treatment in Tanzania. The aims of this study were to determine 5-year overall survival (OS) rate and its predictors among patients with cervical cancer treated at Ocean Road Cancer Institute (ORCI) from January to December 2012. MATERIALS AND METHODS This was retrospective study done at ORCI by reviewing medical charts of 202 patients with cervical cancer treated at ORCI from January to December 2012. A structured questionnaire was used to extract information about characteristics of the respondents. Survival curves were estimated by using Kaplan-Meir analysis and were compared by using log-rank test. RESULTS The 5-year OS rate was 26%. The mean and median survival times were 33.9 and 19 months, respectively. Factors that were positively associated with 5-year OS rate include the hemoglobin level more than 9 g/dL at presentation, early International Federation of Gynecology and Obstetrics stage at presentation, high dose of radiotherapy, and use of concurrent chemoradiotherapy. Histology type and HIV status were not associated with survival. CONCLUSION The 5-year overall survival rate was 26%. Predictors of OS were hemoglobin level, stage at presentation, radiotherapy dose, and the use of concurrent chemoradiotherapy.

Expanding Access to Computed Tomographic Staging and Three-Dimensional Intensity Modulated Radiotherapy for Cervical Cancer in Ghana

PURPOSE To build capacity for improved treatment of locally advanced cervical cancer in Ghana, including computed tomography (CT) staging and intensity modulated radiotherapy (IMRT). MATERIALS AND METHODS Patients with histologically confirmed cervical cancer were prospectively staged with abdominopelvic CT and ultrasound and offered the opportunity to have IMRT instead of conventional two-dimensional radiotherapy. The development of an efficient, high-quality, and safe IMRT program was facilitated by investment in new technology and comprehensive training of the interdisciplinary radiotherapy team in collaboration with a North American center of excellence. RESULTS Of 215 patients with cervical cancer referred in 2022, 66% were able to afford CT scans and 26% were able to afford IMRT. Lymph node metastases were identified in 52% of patients by CT but in only 2% of patients by ultrasound. The use of CT resulted in 63% of patients being upstaged and changed treatment intent or radiation treatment volumes in 67% of patients. Patients who had IMRT experienced fewer acute side effects and were more likely to complete treatment as planned. CONCLUSION It is feasible to provide state-of the-art cancer treatment with CT staging and IMRT to patients with cervical cancer in low-resource settings and achieve meaningful improvements in outcomes. It requires a broad commitment by program leadership to invest in technology and staff training. Major challenges include balancing improved clinical care with reduced patient throughput when radiation treatment capacity is constrained, and with the additional cost in the absence of universal health coverage.

Expanding Cervical Cancer Screening in Mozambique: Challenges Associated With Diagnosing and Treating Cervical Cancer

PURPOSE Mozambique has one of the highest burdens of cervical cancer globally. Treatment options are few as most women present with advanced disease, and there are limited trained health professionals and health care resources. The objective of this study was to describe the outcomes of women diagnosed with invasive cancer as part of the Mozambican women undergoing cervical cancer screening with human papillomavirus (HPV) testing in conjunction with family planning services (MULHER) study. MATERIALS AND METHODS Women age 30-49 years were prospectively enrolled in the MULHER study and offered screening with primary HPV testing followed by treatment of screen-positive women with thermal ablation or excision as appropriate. Women with cervical examination findings suspicious for cancer were referred to one of the three gynecologic oncologists in the country. RESULTS Between January 2020 and January 2023, 9,014 women underwent cervical cancer screening and 30 women were diagnosed with cervical cancer. In this cohort, four patients (13.3%) had early-stage disease, 18 (60.0%) had locally advanced disease, one (3.3%) had distant metastatic disease, and seven (23.3%) did not have staging information available. Five patients (16.6%) died without receiving oncologic treatment, and seven patients (23.3%) are still awaiting treatment. Of the remaining 18 patients, three (17.6%) underwent surgery and four (23.5%) received radiotherapy. Eleven (36.7%) patients received only chemotherapy. CONCLUSION As cervical screening programs are implemented in low-resource settings, there will likely be an increase in the number of women diagnosed with invasive cervical cancer. Our results in Mozambique demonstrate the need to increase access to advanced surgery, radiation, and palliative care services.

HIV and Early Treatment Outcomes Among Women With Cervical Cancer Treated With Concurrent Chemoradiation in Tanzania

PURPOSE Cervical cancer (CC) is the leading malignancy in Tanzania. Low-income countries are faced with double epidemics of HIV and CC. This study aimed to investigate how HIV and cancer stage at diagnosis affect early treatment outcomes among women with CC treated with concurrent chemoradiation in Tanzania in the highly active antiretroviral therapy era. MATERIALS AND METHODS This was a prospective cohort study of patients newly diagnosed with CC at the Ocean Road Cancer Institute from November 2019 to January 2020. The tumor response was assessed using RECIST 3 months post-treatment. The tumor response was categorized as a complete or partial response according to the ultrasound and pelvic examination findings. The univariate and multivariate logistic regression explained the relationship between several covariates (age, stage, HIV status, equivalent dose in 2 Gy fractions, chemotherapy cycles, and treatment time) and treatment response. RESULTS A total of 102 patients with CC were included in this study at baseline. After adjusting for other covariates, only completion of treatment within 56 days (odds ratio [OR], 9.23; 95% CI, 1.53 to 55.85; P = .016) and receiving at least three cycles of cisplatin (OR, 5.6; 95% CI, 1.47 to 21.34; P = .012) were significantly associated with complete tumor response. HIV status was not significantly associated with complete tumor response (OR, 1.534; 95% CI, 0.424 to 5.545; P = .5144). CONCLUSION Early treatment response was independent of HIV status. With wide coverage of anitretroviral therapy, patients with HIV can receive radical treatment and have the same early outcomes as their HIV-negative counterparts.

Concordance in HPV Detection Between Self-Collected and Health Provider–Collected Cervicovaginal Samples Using careHPV in Tanzanian Women

PURPOSE Cervical cancer screening is one of the strategies to prevent the disease among women at risk. Human papillomavirus (HPV) DNA testing is increasingly used as the cervical cancer screening method because of its high sensitivity. Self-collection of cervical specimens has the potential to improve participation. However, there is only limited information on comparison between self-collected and provider-collected samples with regard to detection of high-risk HPV using the careHPV method. The study aimed to compare HPV detection by careHPV in self-collected and provider-collected cervical samples and to assess the acceptability of self-collection techniques. MATERIAL AND METHODS Women attending cervical cancer screening clinics at Ocean Road Cancer Institute, Kilimanjaro Christian Medical Centre or Mawenzi Hospital in Tanzania were included in the study. They underwent a face-to-face interview, HIV testing, and collected a self-sample using Evalyn Brush. Subsequently, they had a cervical sample taken by a health provider. Both samples were tested for high-risk HPV DNA using careHPV. RESULTS Overall, 464 women participated in the study. The high-risk HPV prevalence was 19.0% (95% CI, 15.6 to 22.9) in the health provider samples, but lower (13.8%; 95% CI, 10.9 to 17.3) in the self-collected samples. There was a good overall agreement 90.5% (95% CI, 87.5 to 93.0) and concordance (κ = 0.66; 95% CI, 0.56 to 0.75) between the two sets of samples. Sensitivity and specificity were 61.4% (95% CI, 50.4 to 71.6) and 97.3% (95% CI, 95.2 to 98.7), respectively, varying with age. Most women preferred self-collection (79.8%). CONCLUSION Overall, self-sampling seems to be a reliable alternative to health-provider collection and is acceptable to the majority of women. However, instructions on proper procedures for sample collection to the women are important.

Coverage and Socioeconomic Inequalities in Cervical Cancer Screening in Low- and Middle-Income Countries Between 2010 and 2019

PURPOSE Cervical cancer screening is vital in addressing the global burden of cervical cancer. In this study, we describe the coverage and socioeconomic inequalities in the coverage of cervical cancer screening in low- and middle-income countries (LMICs). METHODS We analyzed data from the women's recode files of the Demographic and Health Surveys conducted in LMICs from 2010 to 2019 with variables on cervical cancer screening. We included women 21 years or older and determined the proportion of women who were screened for cervical cancer by age categories, wealth quintile, type of place of residence, level of education, and marital status. Socioeconomic inequality was measured using the concentration index (CIX) and the slope index of inequality (SII). RESULTS A total of 269,506 women from 20 surveys in 16 countries were included in the survey. Generally, there was a low coverage of screening, with lower rates among women age 21-24 years, living in rural areas, in the poorest wealth quintile, with no formal education, and who have never been in union with or lived with a man. The CIX and SII values for screening for cervical cancer were positive (pro-rich) for all the countries except Tajikistan in 2012 where they were negative (pro-poor). CONCLUSION The coverage of cervical cancer screening was low in LMICs with variations by the quintile of wealth (pro-rich) and type of place of residence (pro-urban). To achieve the desired impact of cervical cancer screening services in LMICs, the coverage of cervical cancer screening programs must include women irrespective of the type of place and wealth quintiles.

Understanding Geospatial Factors Associated With Cervical Cancer Screening Uptake in Amazonian Peruvian Women

PURPOSECervical cancer (CC) is the most common and second-most deadly cancer among Peruvian women. Access to services is strongly associated with CC screening uptake. This study investigated geospatial features contributing to utilization of screening. We used geolocated data and screening information from a Knowledge, Attitudes, and Practice (KAP) survey implemented in Iquitos, Peru in 2017.MATERIALS AND METHODSThe KAP collected cross-sectional CC screening history from 619 female interviewees age 18-65 years within 5 communities of varying urbanization levels. We used spatial statistics to determine if screened households tended to cluster together or cluster around facilities offering screening in greater numbers than expected, given the underlying population density.RESULTSOn the basis of K-functions, screened households displayed greater clustering among each other as compared with clustering among unscreened households. Neighborhood-level factors, such as outreach, communication, or socioeconomic condition, may be functioning to generate pockets of screened households. Cross K-functions showed that screened households are generally located closer to health facilities than unscreened households. The significance of facility access is apparent and demonstrates that travel and time barriers to seeking health services must be addressed.CONCLUSIONThis study highlights the importance of considering geospatial features when determining factors associated with CC screening uptake. Given the observed clustering of screened households, neighborhood-level dynamics should be further studied to understand how they may be influencing screening rates. In addition, results demonstrate that accessibility issues must be carefully considered when designing an effective cancer screening program that includes screening, follow-up, and treatment.

Uptake of Risk-Reducing Surgeries in an International Real-World Cohort of Hispanic Women

PURPOSE Women with pathogenic variants (PVs) in breast cancer (BC) and ovarian cancer (OC) associated genes are candidates for cancer risk-reducing strategies. Limited information is available regarding risk-reducing surgeries (RRS) among Hispanics. The aim of this study was to describe the uptake of RRS in an international real-world experience of Hispanic women referred for genetic cancer risk assessment (GCRA) and to identify factors affecting uptake. METHODS Between July 1997 and December 2019, Hispanic women, living in the United States or in Latin America, enrolled in the Clinical Cancer Genomics Community Research Network registry were prospectively included. Demographic characteristics and data regarding RRS were obtained from chart reviews and patient-reported follow-up questionnaires. Median follow-up was 41 months. RESULTS Among 1,736 Hispanic women referred for GCRA, 27.2% women underwent risk-reducing mastectomy (RRM), 25.5% risk-reducing salpingo-oophorectomy (RRSO) and, 10.7% both surgeries. Among BRCA carriers, rates of RRM and RRSO were 47.6% and 56.7%, respectively. In the multivariate analyses, being a carrier of a BC susceptibility gene (odds ratio [OR], 3.44), personal history of BC (OR, 6.22), living in the US (OR, 3.90), age ≤50 years (OR, 1.68) and, family history of BC (OR, 1.56) were associated with a higher likelihood of undergoing RRM. Carrying an OC susceptibility gene (OR, 6.72) was associated with a higher likelihood of undergoing RRSO. CONCLUSION The rate of RRS among Hispanic women is suboptimal. PV carriers, women with personal history of cancer, and those with a family history of cancer were more likely to have RRS, with less uptake outside the US. Understanding personal and systemic factors influencing uptake may enable interventions to increase risk appropriate uptake of RRS.

Epidemiology of Cervical Cancer in Brazil: Age-Specific Trends From 2000 to 2018

PURPOSE Cervical cancer (CC) remains a significant public health challenge in low- and middle-income countries (LMICs), including Brazil. While global incidence has declined, age-specific variations may mask emerging trends among younger women. This study aimed to evaluate trends and age-specific changes in CC incidence in Brazil between 2000 and 2018. MATERIALS AND METHODS Incidence data and age at diagnosis were obtained from Brazilian Population-Based Cancer Registries (PBCRs) for the period 2000-2018. Temporal trends were evaluated using Joinpoint regression to estimate annual percent changes (APCs) and average APCs (AAPCs). RESULTS Between 2000 and 2018, 66,358 CC cases were identified across 33 PBCRs. The median age at diagnosis was 51 years (IQR, 40-63), declining from 52 years in 2000 to 48 years in 2018. The overall adjusted incidence showed a significant decline between 2000 and 2013 (APC: –4.5% [95% CI, –5.3 to –3.7]; P < .001) followed by a nonsignificant increase from 2013 to 2018 (APC: 3.1 [95% CI, –1.6 to 8.1]; P = .20). Age-stratified analyses revealed rising trends among women age 25-44 years, suggesting a transition to younger age at diagnosis. CONCLUSION The observed decrease in median age and rising incidence among women younger than 45 years indicate a potential epidemiologic shift in CC in Brazil. These findings highlight the need to strengthen national screening programs, expand human papillomavirus (HPV) vaccination coverage, and incorporate molecular HPV testing into prevention strategies.

Global Incidence of Ovarian Cancer According to Histologic Subtype: A Population-Based Cancer Registry Study

PURPOSE Ovarian cancer can be categorized into distinct histologic subtypes with varying identifiable risk factors, molecular composition, clinical features, and treatment. The global incidence of ovarian cancer subtypes remains limited, especially in low- and middle-income countries (LMICs) without high-quality cancer registry systems. MATERIALS AND METHODS We used data from population-based cancer registries of the Cancer Incidence in Five Continents project to calculate the proportions of serous, mucinous, endometrioid, clear cell, and other histologic subtypes of ovarian cancer. Proportions were applied to the estimated numbers of patients with ovarian cancer from Global Cancer Observatory 2020. Age-standardized incidence rates were calculated. RESULTS Globally, an estimated 133,818 new patients of serous cancer, 35,712 new patients of mucinous cancer, 29,319 new patients of endometrioid cancer, and 17,894 new patients of clear cell cancer were identified in 2020. The distribution of ovarian cancer histologic subtypes exhibited regional variation. Eastern Europe had the highest rate of serous and mucinous carcinomas, whereas Northern Africa and Eastern Asia had the highest burden of endometrioid and clear cell carcinomas, respectively. CONCLUSION This study provides a global incidence landscape of histologic subtypes of ovarian cancer, particularly in LMICs lacking comprehensive registry systems. Our analysis offers valuable insights into disease burden and guidance for tailored strategies for prevention of ovarian cancer.

Uptake of Risk-Reducing Measures, Cascade Testing, and Related Challenges Among Carriers of Breast Cancer–Associated Germline Pathogenic Variants in Mexico

PURPOSE Genetic cancer risk assessment (GCRA) provides pathogenic variant (PV) carriers with the invaluable opportunity to undertake timely cancer risk-reducing (RR) measures and initiate cascade testing (CT). This study describes the uptake of these strategies and the related barriers among breast cancer–associated germline PV carriers in Mexico. METHODS Carriers who were at least 6 months after disclosure of genetic test results at two GCRA referral centers were invited to answer a survey assessing sociodemographic characteristics, awareness of their carrier status and its implications, uptake of RR measures according to international guidelines by PV, CT initiation, and associated challenges. RESULTS Of the eligible carriers, 246/384 (64%) answered the survey (median age: 44 years). Most were female (88%), married/in domestic partnership (66%), and had personal breast/ovarian cancer history (61%). PVs included BRCA1/ 2 (75%), CHEK2 (10%), PALB2 (5%), ATM (5%), NF1 (2%), RAD51C (2%), PTEN (1%), and TP53 (1%). Most (87%) participants were aware of their carrier status. When recommended, 37% underwent RR bilateral mastectomy, 48% RR oophorectomy, 70% annual mammogram, and 20% breast magnetic resonance imaging. Challenges hindering the uptake of RR measures included financial limitations (67%), lack of recommendation by their physician (35%), and fear (24%). Nearly all (98%) claimed sharing their results with their relatives. CT was initiated in 63% of families and was associated with carriers being married/in domestic partnership ( P = .04) and believing GCRA was useful ( P < .001). CONCLUSION Despite the resource-constrained setting, relevant rates of RR measures and CT were observed. Targeted interventions to reduce out-of-pocket expenses and improve patient-physician communication and patients' understanding on carrier status are warranted to enhance the overall benefit of GCRA and ultimately improve the provision of patient-centered care to both carriers and their at-risk relatives.

Prognostic Relevance of Molecular Classification in Endometrial Cancer: Insights From a South African Cohort

PURPOSE Geographical and racial diversity may influence endometrial cancer (EC) prognosis, yet its impact remains underexplored. In South Africa (SA), the rising incidence of EC underscores the need to investigate potential biologic differences. Molecular classification of EC offers valuable prognostic insights that could help address disparities and improve care. This study evaluated the prevalence and prognostic significance of molecular subtypes in a South African high-intermediate and high-risk EC cohort. MATERIALS AND METHODS We included 133 patients with high-intermediate and high-risk EC diagnosed in SA between January 2017 and December 2021. Clinical, demographic (including self-identified race), and follow-up data were collected. Central pathology review assessed histotype, grade, lymphovascular space invasion, and International Federation of Gynecology and Obstetrics 2009 stage. Molecular subtyping followed the WHO 2020 algorithm using targeted next-generation sequencing and immunohistochemistry for p53, mismatch repair (MMR) proteins, and ER. Shallow whole-genome sequencing (sWGS) assessed genome-wide copy number alterations. RESULTS Among 131 patients with complete molecular classification, the most common subtype was p53-abnormal (p53abn, n = 71; 54.2%), followed by MMR-deficient (MMRd, n = 30; 22.9%), no specific molecular profile (NSMP, n = 21; 16.0%), and POLE -ultramutated ( POLE mut, n = 9; 6.9%). Nonendometrioid EC (NEEC) predominated (n = 82; 61.7%). High-grade endometrioid EC and NEEC were more frequent in non-White patients ( P = .030). Molecular subtypes were significantly associated with overall recurrence ( P = .029), with no recurrences in POLE mut ECs and the worst outcomes in p53abn ECs. sWGS revealed higher CN burdens in p53abn ECs, with recurrent focal alterations involving CCNE1 amplification and RB1 loss. CONCLUSION To our knowledge, this study is the first to demonstrate the prognostic value of EC molecular classification in a South African cohort. These findings support the global relevance of molecular EC subtyping. The urgent need for access to molecular diagnostics or cost-effective alternatives in resource-limited settings is highlighted.

Prevalence and Survival Outcomes of L1 Cell Adhesion Molecule–Positive in Endometrial Cancer Across Molecular Subtypes: A Systematic Review and Meta-Analysis

PURPOSE L1 cell adhesion molecule (L1CAM) has emerged as a potential prognostic biomarker in endometrial cancer. This systematic review and meta-analysis aimed to comprehensively evaluate the prevalence of L1CAM expression across molecular subtypes of endometrial cancer and its prognostic significance for survival outcomes. MATERIALS AND METHODS A systematic literature search of PubMed, Embase, and Cochrane Library was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies reporting L1CAM expression in endometrial cancer, stratified by molecular subtypes (polymerase epsilon [POLE], mismatch repair deficiency [MMR-D], no specific molecular profile [NSMP], p53 wild type [p53wt], p53 abnormal [p53abn]), and their association with survival outcomes were included. Pooled prevalence and hazard ratios with 95% CIs were calculated using random-effects models. RESULTS Twenty-one retrospective studies met the inclusion criteria. The overall pooled prevalence of L1CAM positivity was 15%. Stratified by molecular subtype, prevalence was the lowest in POLE-mutated tumors (4.87%), followed by p53abn tumors (52.86%), MMR-D tumors (52.16%), NSMP (30.88%), and p53wt (25.99%). L1CAM positivity was significantly associated with worse disease-specific survival (hazard ratio [HR], 2.49 [95% CI, 1.75 to 3.55]) and progression-free survival (HR, 2.50 [95% CI, 1.56 to 4.01]). Subgroup analyses revealed significant associations in MMR-D tumors (HR, 1.75 [95% CI, 1.06 to 2.89]), NSMP tumors (HR, 5.41 [95% CI, 2.92 to 10.03]), and a borderline effect in p53abn tumors (HR, 1.69 [95% CI, 1.00 to 2.85]). CONCLUSION The highest prevalence of L1CAM was found in p53abn endometrial tumors. L1CAM positivity is associated with poor survival outcomes, particularly in MMR-D and NSMP subgroups. These findings highlight the potential of L1CAM as a prognostic biomarker that could refine risk stratification and guide adjuvant management more accurately in endometrial cancer, warranting validation in prospective studies.

Validation of Sentinel Lymph Node Biopsy in Robotic Endometrial Cancer Staging Surgery: Results From a High-Volume Center in India

PURPOSE Lymph node involvement is one of the most important factors influencing recurrence and survival in patients with endometrial cancer (EC). However, the therapeutic role of lymphadenectomy in early-stage disease has been called into question. Sentinel lymph node (SLN) mapping may be an acceptable alternative to omitting lymphadenectomy or performing a complete lymphadenectomy in patients with EC. To validate SLN biopsy (SLNB) using indocyanine green (ICG) dye and near-infrared imaging in the background of comprehensive lymphadenectomy in patients with EC undergoing robotic staging surgery at Tata Medical Center. METHODS This was a single-center, prospective observational study involving patients with EC undergoing robotic staging. Patients received a standardized cervical injection of ICG at the 3- and 9-o'clock positions, with the dye reinjected if mapping failed. Depending on preoperative histology and radiological staging, patients had SLNB or comprehensive systematic lymphadenectomy in addition to SLNB. RESULTS The study included 105 female patients, of whom 71 underwent SLN and full lymphadenectomy and 34 underwent only SLN. There was bilateral mapping in 92 (87.61%) patients, with no mapping in one patient. In 18 patients, ICG dye was reinjected. With the exception of one, the rest had successful mapping after reinjection. The sensitivity of the SLN-ICG algorithm was 92.3%, and the negative predictive value was 98.3%. Ultrastaging necessitated upstaging in 8.57% of patients. CONCLUSION With a very high negative predictive value, SLN mapping with ICG dye has a high degree of diagnostic accuracy in detecting lymph node metastases in EC.

Shared Decision Making in Oncology and Its Implementation in Cervical Cancer Management in the Philippines: A Narrative Review

PURPOSE Shared decision making (SDM) is an approach where clinicians and patients make decisions together using the best available evidence. Although much studied, recognized to be ethically imperative, and recommended in international health policies, it remains poorly implemented. In the Philippines, there are limited studies on patient decision making preferences and SDM. Practical guidance on the implementation of SDM or use of patient decision aids (PtDAs) is often not detailed in existing national clinical practice guidelines in oncology. METHODS We performed a systematic search of Philippine literature on SDM in oncology and an iterative review of international literature on the philosophy and methods of SDM, the utility and effectiveness of PtDAs, and the facilitators and barriers to implementation or usage. We contextualized our review to the cervical cancer management and health service delivery in the Philippines. RESULTS Local literature is limited to five scientific publications and two registered studies. International literature encompasses patient decisional preferences, the role of PtDAs and the standards for their development and evaluation, their effectiveness, and barriers and facilitators to their use in cancer-related decision making. We discussed the implications on the management of cervical cancer in the Philippines, challenges in health service delivery and standards, and SDM research. CONCLUSION Local SDM research is limited. Our preliminary experience in a multicenter clinical trial in Manila on PtDA use in the framework of SDM in cervical cancer suggest good patient and clinician acceptability. Challenges to implementation such as unfavorable financial situations, urgency of clinical decisions, low patient or caregiver educational attainment, and poor integration of multidisciplinary and SDM in organizational workflows will be important when implementing SDM in different settings.

Cervix Cancer in Sub-Saharan Africa: An Assessment of Cervical Cancer Management

PURPOSE Underdeveloped nations carry the burden of most cervical cancer, yet access to adequate treatment can be challenging. This report assesses the current management of cervical cancer in sub-Saharan Africa to better understand the needs of underdeveloped nations in managing cervical cancer. METHODS A pre- and postsurvey was sent to all centers participating in the Cervical Cancer Research Network's 4th annual symposium. The pre- and postsurvey evaluated human papillomavirus and HIV screening, resources available for workup and/or treatment, treatment logistics, outcomes, and enrollment on clinical trials. Descriptive analyses were performed on survey responses. RESULTS Twenty-nine centers from 12 sub-Saharan countries saw approximately 300 new cases of cervical cancer yearly. Of the countries surveyed, 55% of countries had a human papillomavirus vaccination program and 30% (range, 0%-65%) of women in each region were estimated to have participated in a cervical cancer screening program. In the workup of patients, 43% of centers had the ability to obtain a positron emission tomography and computed tomography scan and 79% had magnetic resonance imaging capabilities. When performing surgery, 88% of those centers had a surgeon with an expertise in performing oncological surgeries. Radiation therapy was available at 96% of the centers surveyed, and chemotherapy was available in 86% of centers. Clinical trials were open at 4% of centers. CONCLUSION There have been significant advancements being made in screening, workup, and management of patients with cervical cancer in sub-Saharan Africa; yet, improvement is still needed. Enrollment in clinical trials remains a struggle. Participants would like to enroll patients on clinical trials with Cervical Cancer Research Network's continuous support.

Stigma and Its Association With Social Support and Quality of Life Among Patients With Cervical Cancer in Zambia

PURPOSE Zambia is among the countries with the highest cervical cancer incidence and mortality rates globally. Stigma can hinder treatment adherence and overall quality of life for patients with cervical cancer. Research on this topic, however, is lacking in Zambia. This study aimed to assess the levels of stigma among patients with cervical cancer in Zambia and examine the association between social support and quality of life. METHODS We enrolled patients newly diagnosed with cervical cancer at the Cancer Diseases Hospital in Lusaka, Zambia, from July to October 2024. In-person or telephone interviewers collected information on demographic, clinical, and socioeconomic status before treatment. Stigma was assessed using a modified Perceived Stigma Scale, quality of life using the PROMIS-57, and social support with the Multidimensional Scale of Perceived Social Support. Associations between stigma, social support, and quality of life were analyzed using multivariable logistic regression, adjusting for age, education, income, and cancer stage, with significance set at P < .05. RESULTS A total of 213 participants were included in the study with a response rate of 96%. Of the total participants, 30.5% were classified as having high stigma. High levels of support from family (odds ratio [OR], 0.44 [95% CI, 0.22 to 0.87]) and friends (OR, 0.43 [95% CI, 0.21 to 0.91]) reduced the odds of stigma. Severe anxiety, depression, fatigue, sleep disturbances, pain, poor physical function, and low social well-being were all strongly associated with higher stigma (all P ≤ .004). CONCLUSION Perceived cervical cancer–related stigma in Zambia is associated with limited social support and poorer quality of life. Programs to strengthen social network support, as well as targeted mental health treatment, are needed to improve the well-being of patients with cervical cancer in Zambia.

Prevalence of BRCA1 and BRCA2 Mutations Among Patients With Ovarian, Primary Peritoneal, and Fallopian Tube Cancer in India: A Multicenter Cross-Sectional Study

PURPOSE There are deficient data on prevalence of germline mutations in breast cancer susceptibility genes 1 and 2 ( BRCA1/ BRCA2) in Indian patients with ovarian cancer who are not selected by clinical features. METHODS This prospective, cross-sectional, noninterventional study in nine Indian centers included patients with newly diagnosed or relapsed epithelial ovarian, primary peritoneal, or fallopian tube cancer. The primary objective was to assess the prevalence of BRCA1/ BRCA2 mutations, and the secondary objective was to correlate BRCA1/ BRCA2 status with clinicopathologic characteristics. Mutation testing was performed by a standard next-generation sequencing assay. RESULTS Between March 2018 and December 2018, 239 patients with a median age of 53.0 (range, 23.0-86.0 years) years were included, of whom 203 (84.9%) had newly diagnosed disease, 36 (15.1%) had family history of ovarian or breast cancer, and 159 (66.5%) had serous subtype of epithelial ovarian cancer. Germline pathogenic or likely pathogenic mutations in BRCA1 and BRCA2 were detected in 37 (15.5%; 95% CI, 11.1 to 20.7) and 14 (5.9%; 95% CI, 3.2 to 9.6) patients, respectively, whereas variants of uncertain significance in these genes were seen in four (1.7%; 95% CI, 0.5 to 4.2) and six (2.5%; 95% CI, 0.9 to 5.4) patients, respectively. The prevalence of pathogenic or likely pathogenic BRCA mutations in patients with serous versus nonserous tumors, with versus without relevant family history, and ≤ 50 years versus > 50 years, were 40 of 159 (25.2%; 95% CI, 18.6 to 32.6) versus 11 of 80 (13.8%; 95% CI, 7.1 to 23.3; P = .0636), 20 of 36 (55.6%; 95% CI, 38.1 to 72.1) versus 41 of 203 (20.2%; 95% CI, 14.9 to 26.4; P < .0001), and 20 of 90 (22.2%; 95% CI, 14.1 to 32.2) versus 31 of 149 (20.8%; 95% CI, 14.6 to 28.2; P = .7956), respectively. CONCLUSION There is a high prevalence of pathogenic or likely pathogenic germline BRCA mutations in Indian patients with ovarian cancer.

Association Between Male Circumcision and Cervical Cancer Risk: A Systematic Review and Meta-Analysis of Analytical Studies

PURPOSE Cervical cancer is the second most commonly diagnosed cancer and one of the leading causes of death in women. The objective of the current review was to synthesize the available evidence on the association between male circumcision and risk of cervical cancer in females. METHODS We searched PubMed, Cochrane, CancerLit, Google Scholar, medRxiv, bioRxiv, UpToDate, TRIP database, and the ProQuest Dissertations and Theses Global databases to identify relevant articles. We considered research studies that assessed male circumcision status and cervical cancer in females for inclusion. The risk-of-bias assessment was performed using the Newcastle-Ottawa scales. We estimated summary measures of effect and 95% CIs for the odds of developing cervical dysplasia, carcinoma in situ, or invasive cervical cancer in females based on the circumcision status of their male partners. RESULTS We identified 380 potentially eligible records through systematic database searches. After excluding 278 records on the basis of title and abstract screening, 102 full-text records were assessed for eligibility. We included 19 studies in the final analysis. The risk-of-bias assessment revealed a low risk across 10 records. Male circumcision was associated with decreased odds of cervical cancer (odds ratio [OR], 0.65 [95% CI, 0.53 to 0.79]). Circumcision was also associated with decreased odds of developing Invasive cervical cancer (OR, 0.71 [95% CI, 0.51 to 0.99]), cervical dysplasia (OR, 0.65 [95% CI, 0.45 to 0.92]), and carcinoma in situ cervix (OR, 0.67 [95% CI, 0.50 to 0.90]). CONCLUSION Male circumcision has been found to be associated with lower odds of developing various cervical lesions, suggesting its prophylactic potential. Understanding the effects of male circumcision on human papillomavirus (HPV) infection would have important implications for studies of HPV transmission, leading to a better understanding of the pathogenesis of cervical cancer.

Screen, Notify, See, and Treat: Initial Results of Cervical Cancer Screening and Treatment in Rwanda

PURPOSE To describe the first year results of Rwanda's Screen, Notify, See, and Treat cervical cancer screening program, including challenges encountered and revisions made to improve service delivery. METHODS Through public radio broadcasts, meetings of local leaders, church networks, and local women's groups, public awareness of cervical cancer screening opportunities was increased and community health workers were enlisted to recruit and inform eligible women of the locations and dates on which services would be available. Screening was performed using human papillomavirus (HPV) DNA testing technology, followed by visual inspection with acetic acid (VIA), and cryotherapy, biopsy, and surgical treatment for those who tested HPV-positive. These services were provided by five district hospitals and 15 health centers to HIV-negative women of age 35-45 and HIV-positive women of age 30-50. Service utilization data were collected from the program's initiation in September 2013 to October 2014. RESULTS Of 7,520 cervical samples tested, 874 (11.6%) screened HPV-positive, leading 780 (89%) patients to undergo VIA. Cervical lesions were found in 204 patients (26.2%) during VIA; of these, 151 were treated with cryoablation and 15 were referred for biopsies. Eight patients underwent complete hysterectomy to treat advanced cervical cancer. Challenges to service delivery included recruitment of eligible patients, patient loss to follow-up, maintaining HIV status confidentiality, and efficient use of consumable resources. CONCLUSION Providing cervical cancer screening services through public health facilities is a feasible and valuable component of comprehensive women's health care in resource-limited settings. Special caution is warranted in ensuring proper adherence to follow-up and maintaining patient confidentiality.

Linking Microbiome Diversity and Immune Profiles in Ethiopian Patients With Cervical Cancer

PURPOSE This study investigates the interplay between T-cell receptor (TCR) immune characteristics and microbiome profiles to explore the relationship between immune diversity and microbial composition in cervical samples from Ethiopia. METHODS Cervical specimens were collected from patients at Tikur Anbessa Specialized Hospital in Addis Ababa, and rural Butajira, south-central Ethiopia. Patient data, including age, human papillomavirus status, pathology, and TCR immune characteristics, were analyzed with a focus on the interactions between TCR profiles and microbiome compositions in malignant samples. RESULTS Three distinct TCR profiles were identified: Group 1 (TCR active) exhibited features of active immune engagement, including high diversity, clonal expansion, and repertoire richness. Group 2 (TCR restricted) showed reduced TCR diversity and expansion, suggesting a restricted repertoire. Group 3 (TCR balanced) had moderate diversity and clonal activity. TCR repertoire groups were linked with microbial diversity, with Group 1 (TCR active) showing the highest number of microbes (high operational taxonomic units and microbial diversity). Maximum TCR clonal expansion positivity associated with microbial richness, while Group 3 (TCR balanced) was linked to reduced microbial alpha diversity. Taxonomic analysis revealed specific organisms enriched in TCR repertoire group. CONCLUSION Variations in TCR profiles are linked to distinct microbial environments in cervical cancer with greater microbial richness in patients with greater maximum productive frequency. These findings underscore the interplay between TCR diversity, microbiome composition, and malignancy, offering insights into the potential implications for microbiome-targeted therapies and prognostic biomarkers in cervical cancer.

Brachytherapy Workflow Practices: Analysis of Different Workflow Scenarios in Patients With Cervical Cancer and Impact on IGBT Implementation—An IAEA Study

PURPOSE The workflow of brachytherapy (BT) is an essential aspect of treatment to consider in image-guided brachytherapy (IGBT). It has an overarching effect influencing patient throughput and the number of cancer treatments that can be performed as it occupies equipment, space, and personnel. There is limited research addressing this issue. Under the International Atomic Energy Agency's Coordinated Research Activity titled IGBT for cervix cancer: An implementation study, our study analyzes various scenarios in the clinical workflow of BT delivery for cervical cancer. It aims to determine the extent to which these scenarios allow the routine implementation of IGBT. With this information, current barriers and individualized adaptations to efficient workflows can be identified to enhance the global application of IGBT, leading to better cervical cancer treatment. MATERIALS AND METHODS A web-based poll of questions regarding practices in BT workflow was presented to 62 participants from low-, lower middle-, upper middle-, and high-income countries (19 countries). RESULTS This study highlighted diversity in BT practices across countries, income levels, and regions. It identified variations in workflow, patient throughput, and resource availability, which can have implications for the efficiency and quality of BT treatments. Scenario A, utilizing multiple locations for the steps of the BT procedure, was the most commonly used. The availability of resources, such as imaging devices and trained personnel, varied among the participating centers and remained challenging for IGBT implementation and sustainability. CONCLUSION The design of the BT facility plays a vital role in improving efficiency, with a dedicated BT suite contributing to an efficient workflow but limiting patient throughput, especially for high-volume centers. Although IGBT is effective, its implementation requires consideration of various logistical challenges and should be individualized.

Cervical and Tumor-Associated Microbiomes in Botswana Women With and Without HIV With Carcinoma of the Cervix Before and After Definitive Chemoradiation

PURPOSE Cervical cancer remains a significant public health concern globally and particularly in sub-Saharan Africa, where high rates of HIV infection exacerbate cervical cancer incidence. Understanding the cervical microbiome and its role in cancer progression is essential, especially in regions where both cervical cancer incidence and HIV prevalence are high. This study aimed to characterize the cervical microbiome in women living with HIV (WLWH) and HIV-negative women with squamous cell carcinoma of the cervix in Botswana, compare the microbiome between before and after chemoradiation therapy (CRT) in WLWH, and assess the prognostic value of specific microbial taxa for overall survival (OS) in WLWH. PATIENTS AND METHODS Cervical samples were collected from women with cervical cancer presenting to one hospital in 2018-2019. Patients' clinical data, including HIV status, were recorded. Microbial composition was analyzed using 16S rRNA gene sequencing. Microbiome diversity and composition were evaluated using alpha and beta diversity metrics. Differential microbial abundance was analyzed using linear discriminant analysis effect size. The association between microbial taxa and OS was explored using Cox proportional hazards regression. RESULTS WLWH (n = 42) had a significantly lower Pielou evenness index than HIV-negative women (n = 11; 0.6 v 0.7, P = .02), suggesting a more imbalanced microbiome in WLWH. WLWH had higher levels of Parvimonas and members of the Corynebacteriaceae and Micrococcaceae families, suggesting a shift toward a more pathogenic microbiome. In WLWH, CRT did not significantly alter overall microbial diversity. However, Lactobacillus and Sutterella were enriched before treatment, reflecting a less pathogenic microbiome, whereas Ruminococcus and Phascolarctobacterium and the families Caulobacterales and Flavobacteriia were enriched after treatment, reflecting microbial adaptations to the altered immune and treatment environment. Notably, higher levels of Flavobacteriia after CRT were independently associated with worse OS in WLWH. CONCLUSION Microbiome profiles differ between WLWH and HIV-negative women with cervical cancer in Botswana. The microbiome might have prognostic significance. Future research is needed to better understand the significance of the microbiota in cervical cancer progression and treatment outcomes and the potential role of microbiome-targeted interventions.

Association Between the Test-and-Treat Strategy and the Severity of Cervical Dysplastic Lesions Among Women Living With HIV in Tanzania (2015-2023)

PURPOSE Cervical cancer remains a leading cause of morbidity and mortality in Tanzania where HIV exacerbates the risk of cancer and dysplasia. In 2017, Tanzania adopted the Test-and-Treat program for patients with HIV, which mandates immediate antiretroviral therapy for people living with HIV, regardless of CD4 count. This study examined the impact of this strategy on the severity of cervical dysplasia among women living with HIV (WLWH) at the Ocean Road Cancer Institute (ORCI). METHODS We used existing data of women who came to the ORCI cervical cancer early detection clinic between 2015 and 2023 for cervical cancer early detection. Of the 3,385 women screened, 1,686 were diagnosed with dysplastic lesions and included in the analysis. This subset consisted of 349 WLWH, 605 HIV-negative women, and 732 women with unknown HIV status. The remaining women either were visual inspection with acetic acid–negative or had suspected cervical cancer and were not included in the final analysis of dysplastic lesions. The year 2017 was chosen as a pivotal point for analysis because it marked the implementation of the Test-and-Treat strategy at the ORCI. The severity of dysplasia before and after 2017 was compared using trend and logistic regression analyses. RESULTS The Test-and-Treat strategy was associated with a significant increase in detecting small/moderate lesions ( P < .0001). The odds of being diagnosed with small/moderate lesions versus large lesions were approximately four times higher post-2017 (odds ratio, 3.972 [95% CI, 2.462 to 6.409]). CONCLUSION The Test-and-Treat strategy has significantly reduced the severity of cervical dysplasia among WLWH at the ORCI, highlighting the importance of integrating HIV treatment into cervical cancer prevention programs. Continuous research focusing on the long-term effects of the Test-and-Treat strategy and expansion of on-site pathology services, including timely histopathologic diagnosis, are essential to further reduce cervical cancer incidence, morbidity, and mortality among WLWH.

Diagnostic Translational Considerations for Global Health Settings: Portable Detection of Human Papillomavirus for Cervical Cancer Screening in India

PURPOSE Translation of diagnostic technology developed at the laboratory bench involves iterations of user feedback and design modifications. Learning about translational requirements early in the design process facilitates the development of feasible prototypes that have a better likelihood of implementation in global health settings. During our development of a portable system to detect human papillomavirus (HPV) for cervical cancer screening in India, we encountered and solved issues related to research translation. We report our findings to help others deploying diagnostic technology for global health. MATERIALS AND METHODS We designed a point-of-care system to process patient samples and diagnose HPV infection in the cervix. We continually shipped components of the system from the United States to our collaborating team in India to assess component condition and usability at the local site. We simultaneously developed HPV isothermal amplification assays that were fit for purpose. Cervical brush samples were used in our portable system for functional validation. RESULTS We found ideal transport methods to ensure component quality and reagent stability through the international shipment chain. Portable systems should be designed as simple as possible for correct usage at the local testing site. Usability tests drove our design improvements from 28% to 93% success rates. We demonstrated proof-of-concept functionality of our portable system for 13 cervical brush samples on-site, with a sensitivity of 100% and specificity of 88.9%. CONCLUSION Issues related to technology transfer for global health settings manifest during distribution and deployment of prototypes. We identified several issues during our synergistic design process and report recommendations on the basis of our experience.

Treatment Outcome and Chemoresistance-Related Factors of Low-Risk Gestational Trophoblastic Neoplasia: Results From a Tertiary Care Center in Saudi Arabia

PURPOSE Gestational trophoblastic neoplasia (GTN) is a highly curable malignancy classified using the International Federation of Gynecology and Obstetrics (FIGO)/WHO scoring system into low-risk (score 0-6) and high-risk (score ≥ 7) categories. Although single-agent chemotherapy is standard for low-risk GTN, patients with FIGO scores of 5-6 exhibit disproportionately high rates of chemoresistance, raising concerns about current classification and treatment strategies. METHODS This retrospective analytic study included 162 patients with low-risk GTN treated at a tertiary referral center in Saudi Arabia from 1980 to 2021. Patients were stratified into FIGO score subgroups (0-4 v 5-6), and data on demographics, treatment regimens, outcomes, and chemoresistance were collected. The primary outcome was resistance to first-line chemotherapy. Multivariable logistic regression identified independent predictors of chemoresistance. RESULTS The median patient age was 35 years, with 64.8% age 40 years and younger. Hydatidiform mole was the most common antecedent pregnancy (88.9%), and 30.9% had FIGO scores of 5-6. First-line treatment included single-agent chemotherapy (74.7%) and multiagent regimens (25.3%). Although all patients achieved complete remission, 26.5% exhibited chemoresistance to first-line treatment, significantly associated with treatment before the year 2000, higher FIGO scores, and single-agent chemotherapy. On multivariable analysis, FIGO scores of 5-6 (odds ratio [OR], 2.6; P = .02) and single-agent chemotherapy (OR, 0.11; P = .007) were independent predictors of resistance. β-human chorionic gonadotropin (hCG) level was the only FIGO component independently linked to chemoresistance. Relapse occurred in 5.4% of cases. CONCLUSION Patients with FIGO scores of 5-6 and high β-hCG levels had increased resistance to first-line therapy. β-hCG was the strongest independent predictor. These findings highlight the need to reassess treatment strategies for this subgroup.

Impact of Waiting Time and Treatment Duration on Short-Term Outcomes for Patients With Locally Advanced Cervical Cancer at the Uganda Cancer Institute: The Challenges in Resource-Limited Settings

PURPOSE Cervical cancer remains a significant public health burden, especially in sub-Saharan Africa. The waiting time and treatment duration are key indicators of quality in oncology care, and guidelines recommend that chemoradiation for patients with locally advanced cervical cancer (LACC) should be completed within 8 weeks. This study aimed to quantify waiting times and treatment durations for LACC at the Uganda Cancer Institute and identify bottlenecks in the radiotherapy treatment pathway. MATERIALS AND METHODS This prospective study involved 196 patients with LACC. The department’s treatment protocol for LACC allows either conventional fractionated radiotherapy (CFRT) at 50 Gy/25# or hypofractionated radiotherapy (HFRT) at 45 Gy/15#, followed by brachytherapy at 24 Gy/3#. Nine key treatment milestones were documented from diagnosis to brachytherapy completion. The impact of social determinants of health on waiting times was analyzed. Responses were assessed 6 months after treatment completion. RESULTS Patients spent a median delay time of 41 days and a median waiting time of 88 days. The median external beam radiation therapy duration was 40 days for CFRT, compared with 24 days for HFRT. The median waiting time before initiating brachytherapy was 40 days, leading to an overall treatment duration of 85 days for CFRT and 66 days for HFRT. Only 18% of patients on CFRT and 37% of patients on HFRT completed within timelines. The proportions of patients with either waiting times or treatment duration of ≤8 weeks who had complete responses were comparatively greater than those who started treatments after >8 weeks. CONCLUSION Only 25% completed treatment within the recommended timelines. The long waiting time for brachytherapy makes it impossible to finish within timelines. Strategies to expedite access to brachytherapy are necessary to enhance radiotherapy quality.

Use of Thermal Ablation in Low-Resource Settings: Experience From Three Multicenter Noninferiority Randomized Clinical Trials

PURPOSE Thermal ablation (TA) is now a widely used treatment for cervical precancer in low- and middle-income countries. Over the past decade, TA devices have been redesigned to be more portable, user-friendly, and affordable. This analysis combines data from three large randomized clinical trials comparing the efficacy, safety, and acceptability of TA with those of the previous standard, gas-based cryotherapy. METHODS This analysis used Human Papillomavirus (HPV) test results at 1-year post-treatment as the primary outcome. Secondary outcomes included side effects and patient satisfaction. RESULTS Of the 2,948 participants treated with either TA or gas-based cryotherapy, 80.9% and 81.8% completed HPV testing at 1 year, respectively. Overall, 60.7% tested negative for HPV at follow-up, with slightly higher rates in the TA group (62.5%) compared with cryotherapy (58.7%), although the difference was not statistically significant ( P value = .14). Side effects were minimal for both treatments. Severe pain was slightly more common with TA (7.6% v 3.9% for cryotherapy), but vasovagal responses were less frequent (2.3% v 7.6%). Satisfaction with treatment was high (approximately 98%) across both groups. CONCLUSION Our findings support the efficacy of TA in treating cervical precancer, offering an effective and practical alternative in low-resource settings. However, future research is urgently needed to address critical questions, including the standardization of treatment protocols and tailored approaches for women living with HIV.

Cervical Cancer Outcomes in Mozambique: Impact of an International Gynecologic Oncology Training Program

PURPOSE Cervical cancer is the most common cancer among women in Mozambique and is a major health burden. Surgery for cervical cancer is currently performed at only one hospital in the country, Maputo Central Hospital. Before 2020, there were no gynecologists in Mozambique trained to care for women with cervical cancer. In 2017, the International Gynecologic Cancer Society (IGCS) started a gynecologic oncology training program in Mozambique, and in 2020, the first three fellows graduated from this program. The main objective of this study was to report the outcomes of patients with cervical cancer who were treated surgically by the three newly trained Mozambican gynecologic oncologists. METHODS We performed a retrospective chart review of women diagnosed with cervical cancer who underwent surgical treatment by the Mozambican gynecologic oncologists between November 2020 and October 2022. The outcome of interest was survival at 2 years. RESULTS Thirty-three patients underwent radical hysterectomy with pelvic lymphadenectomy for cervical cancer treatment. The median age at diagnosis was 43 years. After surgery, 15 patients (45%) were dispositioned to surveillance and 18 (55%) were referred for adjuvant treatment with radiotherapy and/or chemotherapy. All patients had follow-up data available, with a median follow-up time of 19 months (range, 0.2 to 37.5). Only one patient died, and the overall survival is 95.7% (95% CI, 87.7% to 100%) at 12.7 months. CONCLUSION The IGCS program has provided training to physicians at Maputo Central Hospital, resulting in surgery for cervical cancer being available to patients in Mozambique. This is an important step in the global elimination of cervical cancer.

Availability and Uptake of Cervical Cancer Screening and Treatment Services at 19 Kenyan Health Facilities: A Brief Report

PURPOSE In 2012, Kenya announced its commitment to prioritizing cervical cancer (CC) services with the National Cervical Cancer Prevention Program. However, gaps in implementation remain, causing suboptimal uptake. The goal of this study is to provide a situational analysis of 19 government health facilities in Kenya to assess facilities' capacity to provide CC screening and treatment. METHODS We conducted a retrospective data review at 19 health facilities in Siaya and Busia counties of Kenya from September 2021 to September 2022 to assess availability and uptake of CC services. Key variables included hospital volume, positivity, and numbers of women screened, treated, and referred. Notes were taken to document challenges with service provision and data collection. The retrospective review informed site matching for a proposed cluster-randomized trial. RESULTS There were a total of 16,757 CC screenings or rescreenings documented across the 19 study sites during the study period. Across the 19 facilities, 10.8% of the women enrolled in care at the hospital were screened during the data collection period. The overall positivity was 3.8% but ranged from 0.7% to 16.7%. Of the 19 facilities offering CC screening, five lacked the required equipment to provide same-day treatment, and complex referral pathways were noted for women needing to seek care elsewhere. Challenges with documentation were noted at all stages of CC services. CONCLUSION Gaps noted were low screening rates, opportunities to improve the efficiency of CC services, structural limitations in implementing the screen-and-treat approach, and poor documentation of CC services and outcomes. Urgent action is needed to ensure that all facilities offering CC screening are equipped with the personnel, supplies, and equipment necessary to conduct guideline-adherent same-day cryotherapy or thermal ablation treatment and improve documentation at the facility level to track CC services across the cascade of care.

Insights Into Cancer Awareness and Health Practices in Rural Kenya: A Cross-Sectional Study of Esophageal, Breast, Prostate, Cervical, and Colorectal Cancers

PURPOSE In sub-Saharan Africa (SSA), there has been an epidemiologic transition from infectious diseases to noncommunicable diseases, including a projected doubling in incidence of cancer. Understanding the underlying factors driving this surge is crucial for designing effective strategies to mitigate the cancer burden. This study focuses on assessing knowledge, attitudes, screening practices, and health behaviors related to five most prevalent cancers in SSA: prostate, breast, cervical, esophageal, and colorectal—among a predominantly rural coastal population in Kenya. MATERIALS AND METHODS We used a cross-sectional study design targeting 1,500 adult respondents randomly selected from an existing community health and demographic surveillance system. Face-to-face interviewer-administered questionnaires were used to collect data. RESULTS One thousand four hundred fifty-two adults participated in the final survey. Breast cancer awareness was highest (69.1%), while awareness of colorectal cancer was lowest (34.6%). Given a list of possible risk factors and symptoms, most respondents (>50%) could only recognize one to two per cancer type. Perceptions of survival from colorectal cancer were particularly pessimistic, with <70% recognizing early detection as a means to improve survival outcomes. In terms of cancer-associated risk factors, more men engaged in tobacco and alcohol use (20.5% and 22.4%, respectively). Additionally, fewer than 10% of eligible participants had ever undergone cancer screening. CONCLUSION This study addresses a gap in population-level Knowledge, Attitudes, and Practices studies in rural SSA, offering insights crucial for cancer prevention, early detection, and treatment. The low awareness and knowledge levels and unhealthy behaviors emphasize a need for targeted educational campaigns at community level and enhanced understanding of barriers to uptake of screening if we are to effectively combat the growing cancer burden in this region.

Improving the Sensitivity-Specificity Balance of Human Papillomavirus Testing on Self- and Clinician-Collected Samples in South Africa

PURPOSE Human papillomavirus (HPV) testing on self-collected samples may increase coverage of cervical cancer screening, but previous studies have observed lower specificity of HPV testing in self- versus clinician-collected samples. Here we investigate strategies to improve the sensitivity-specificity balance of a round of HPV testing on self-collected samples. MATERIALS AND METHODS Women living with and without HIV, age 30-65 years, were recruited in South Africa. Self-collected vaginal samples and clinician-collected cervical samples were tested with Xpert HPV, an assay that detects the 14 high-risk HPV types in five separate channels: (P1) HPV 16; (P2) HPV 18, 45; (P3) HPV 31, 33, 35, 52, 58; (P4) HPV 51, 59; and (P5) HPV 39, 56, 66, 68. All women underwent colposcopy with histology sampling, and diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) was determined by adjudicated pathology. The AUC and related performance parameters were calculated using logistic regression with the cycle threshold (Ct) values of the channels as predictors. RESULTS HPV prevalence in women without and with HIV was higher in self-collected (25.1% v 61.5%) than in clinician-collected samples (16.2% v 48.4%). The optimal model to predict CIN2+ used Ct values from the three channels that detect HPV 16, 18, 45, 31, 33, 35, 52, and/or 58. AUC was superior for testing on clinician-collected (0.908) than on self-collected samples (0.878; P = .0261) in women without HIV, as well as for women living with HIV (0.868 v 0.819; clinician v self; P = .0002). Alternate approaches to handling multiple types and sequential testing approaches did not allow self-testing to achieve equivalent performance to testing on clinician-collected samples. CONCLUSION Using more stringent Ct cutoffs on the three channels that detect the eight highest-risk HPV types can improve the sensitivity-specificity balance of a round of screening in both self- and clinician-collected samples. Although performance of HPV testing on self-collected samples is excellent, performance parameters are better on clinician-collected samples.

Development and Clinical Validation of Visual Inspection With Acetic Acid Application-Artificial Intelligence Tool Using Cervical Images in Screen-and-Treat Visual Screening for Cervical Cancer in South India: A Pilot Study

PURPOSE The burden of cervical cancer in India is enormous, with more than 60,000 deaths being reported in 2020. The key intervention in the WHO's global strategy for the elimination of cervical cancer is to aim for the treatment and care of 90% of women diagnosed with cervical lesions. The current screen-and-treat approach as an option for resource-limited health care systems where screening of the cervix with visual inspection with acetic acid application (VIA) is followed by immediate ablative treatment by nurses in the case of a positive test. This approach often results in overtreatment, owing to the subjective nature of the test. Unnecessary treatments can be diminished with the use of emerging computer-assisted visual evaluation technology, using artificial intelligence (AI) tool to triage VIA-positive women. The aim of this study was (1) to develop a VIA-AI tool using cervical images to identify and categorize the VIA-screen–positive areas for eligibility and suitability for ablative treatment, and (2) to understand the efficacy of the VIA-AI tool in guiding the nurses to decide on treatment eligibility in the screen-and-treat cervical screening program. METHODS This was an exploratory, interventional study. The VIA-AI tool was developed using deep-learning AI from the image bank collected in our previously conducted screening programs. This VIA-AI tool was then pilot-tested in an ongoing nurse-led VIA screening program. RESULTS A comparative assessment of the cervical features performed in all women using the VIA-AI tool showed clinical accuracy of 76%. The perceived challenge rate for false positives was 20%. CONCLUSION This novel cervical image–based VIA-AI algorithm showed promising results in real-life settings, and could help minimize overtreatment in single-visit VIA screening and treatment programs in resource-constrained situations.

Novel Strategy of Training the Accredited Social Health Activists via Application-Based Telemedicine for Cervical Cancer Screening by Human Papillomavirus Self-Sampling: The TRACK Study

PURPOSE This pilot study is aimed to analyze a novel strategy of cervical cancer screening by training of Accredited Social Health Activist (ASHA) workers via telemedicine to counsel women for human papillomavirus (HPV) self-sampling. MATERIALS AND METHODS This is a pilot, community-based, prospective, single-arm study. Physicians trained the ASHA workers regarding self-sampled HPV testing via a mobile application and telephonically using videos and e-pamphlets, who in turn trained the clients in community. The HPV kits were transported via prepaid courier service. RESULTS Four hundred and sixty-five women of age group 30-65 years were tested by 47 teletrained ASHA workers. The mean age of ASHA worker and clients was 39.47 ± 6.45 and 37.26 ± 8.38 years, respectively. Of the ASHA workers, 91.7% were satisfied with the information provided during telecounseling, 95.7% could understand the contents of mobile app easily, and 93.6% could fill the data of clients in app easily. Of the clients, 99.6% were satisfied with counseling by ASHA workers and 98% found it easy to self-sample. The acceptability of this strategy among clients was 58.2%. The feasibility of this strategy (percentage of clients who find it easy/those who did self-sampling) was around 99%. Among those screened, 11.8% were high-risk HPV-positive and 85.5% had follow-up at the study center. CONCLUSION The current study highlights a novel strategy of cervical cancer screening by incorporating the role of telemedicine in training ASHA workers and their role in improving the screening by home-based delivery of HPV kits with promising results.

Erratum: If I Have the Courage…I Prefer to See a Doctor: A Qualitative Exploration of Ethiopian Women's Hesitancy to Screen for Cervical Cancer Using HPV Self-Sampling

Erratum: Imparting Knowledge to Others: A Qualitative Study Exploring How Ethiopian Women Prefer to Receive Cervical Cancer Education

Toward a Framework to Assess the Financial and Economic Burden of Cervical Cancer in Low- and Middle-Income Countries: A Systematic Review

PURPOSE To review the economic burden assessment of cervical cancer in low- and middle-income countries (LMICs) and use the findings to develop a pragmatic, standardized framework for such assessment. METHODS We first systematically reviewed articles indexed in scientific databases reporting the methodology for collecting and calculating costs related to the cervical cancer burden in LMICs. Data on study design, costing approach, cost perspective, costing period, and cost type (direct medical costs [DMC], direct nonmedical costs [DNMC], and indirect costs [IC]) were extracted. Finally, we summarized the reported limitations in the methodology and used the solutions to inform our framework. RESULTS Cervical cancer treatment costs across LMICs vary greatly and can be extremely expensive, up to 70,968 International US dollars. Economic and financial assessment methods also vary greatly across countries. Of the 28 reviewed articles, 25 studies reported DMC for cervical cancer treatment by extracting cost information from billing or insurance databases (eight studies), conducting surveys (five), and estimating the costs (12). Only 11 studies—mainly through surveys—reported DNMC and IC. The economic burden assessment framework includes health care/payer and societal perspectives (DMC, DNMC, IC, and human capital loss) across the cervical cancer screening and treatment continuum. To assess health care/payer costs, we recommend combining the predefined treatment standards with actual local treatment practices, multiplied by unit costs. To assess societal costs, we recommend conducting a cost survey in line with a standardized yet adaptable protocol. CONCLUSION Our standardized, pragmatic framework allows assessment of economic and financial burden of cervical cancer in LMICs despite the different levels of available resources across countries. This framework will facilitate global comparisons and monitoring and may also be applied to other cancers.

Culturally Competent Education and Human Papillomavirus Self-Sampling Achieves Healthy People 2030 Cervical Screening Target Among Low-Income Non-Hispanic Black and Hispanic Women

PURPOSE Disparities in cervical cancer screening, incidence, and mortality exist in the United States. Cervical cancer incidence and mortality rates in Texas are 20% and 32% higher, respectively, than national averages. Within Texas, these rates are significantly higher among non-Hispanic (NH) Black and Hispanic women. Cervical cancer screening uptake is lower among NH Black and Hispanic women (72.9% and 75.9%, respectively) compared with White women (85.5%) in Texas. METHODS During March-August 2023, we conducted a pilot study that offered culturally competent education and human papillomavirus (HPV) self-sampling kits to women in two public housing projects in Houston, TX, that have predominantly NH Black or Hispanic residents. Among those eligible for cervical cancer screening, 35% (n = 24) of the NH Black and 34% (n = 16) of the Hispanic women were found to be underscreened per the US Preventive Services Task Force Guideline. We recruited 40 (24 NH Black and 16 Hispanic) eligible women for our study. The study was approved by the MD Anderson institutional review board and registered with ClinicalTrials.gov ( NCT04614155 —March 11, 2020). RESULTS Seventy-five percent of the NH Black and 87% of the Hispanic participants completed the HPV self-sampling procedures per protocol. Samples of 17% NH Black and 12% Hispanic participants showed a performance error. Overall, cervical cancer screening uptake improved from 65% to 91% among NH Black and from 66% to 96% among Hispanic participants. CONCLUSION Culturally competent education and HPV self-sampling resulted in remarkable improvement in cervical cancer screening uptake among underscreened NH Black and Hispanic women residents of Houston public housing projects. Implementing this strategy could significantly reduce cervical cancer incidence and mortality among similar populations in the United States and globally.

Lessons Learned From 7 Years of Implementing Cervical Cancer Screening and Treatment in Equatorial Guinea

PURPOSE This study aimed to assess the results of the Cervical Cancer Screening and Treatment (CCST) project in Equatorial Guinea and the reach of facility-based and community outreach service delivery strategies. MATERIALS AND METHODS The CCST project implemented the single-visit, screen-and-treat approach, using visual inspection with acetic acid (VIA) and treatment with cold coagulation (and referral for further evaluation where needed) for women age 20-60 years. The project deployed two service delivery strategies: in health facilities and through community outreach. The project conducted cascaded training, routine supervision for quality improvement, communication campaigns, and community mobilization efforts. RESULTS Between 2017 and 2023, 26,998 women were screened. The two strategies reached almost equal numbers of women. Community outreach reached more women in the country's mainland. It also reached significantly more married women, women with age at first sexual intercourse at or before 16 years, and those who were puerperal, postmenopausal, and multiparous than facility-based screening. VIA positivity rate was 2.6% overall, with higher rates among younger women. Fifty-five percent of VIA-positive women were treated with cold coagulation, 10% were referred for further evaluation, and 18% received no treatment. CONCLUSION To our knowledge, this first-ever effort in CCST in Equatorial Guinea has shown that both facility-based and community outreach are effective in implementing the single-visit, screen-and-treat approach and underscores the need to continue and further expand the effort, strengthen the quality of services delivered and data capture, and increasingly transfer the capacity to implement facility-based screening and community outreach to the Ministry of Health.

Patterns of Treatment and Outcomes in Epithelial Ovarian Cancer: A Retrospective North Indian Single-Institution Experience

PURPOSEOvarian cancer (OC) is ranked as the third most common gynecologic cancer in various Indian cancer registries. In India, OC is seen in the younger age group, with a median age < 55 years being reported by most of the studies. The majority of patients are diagnosed in advanced stage (70%-80%), where the long-term (10-year) survival rate is poor, estimated at 15%-30%. The aim of this study was to evaluate clinical epidemiology, treatment patterns, and survival outcomes in patients with epithelial OC.METHODSThis was a retrospective analysis of patients with epithelial OC who were treated at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, over a period of 9 years, from January 2010 to December 2018.RESULTSOC constituted 2.94% of all cancers registered. Epithelial OC constituted 88.4% of all OCs, with a median age 50 years. More than two third of patients belonged to rural background and the majority (76.9%) of the patients were in stage III or IV at the time of diagnosis. The main presenting symptoms were abdominal distension/bloating (46.5%) and gastrointestinal disturbances (35.2%). The most common histologic types were serous (65.9%) followed by mucinous carcinoma (15%). Median overall survival for the whole study cohort was 30 months (95% CI, 28.0 to 31.9). Median overall survival for stage I, II, III, and IV was 72, 60, 30, and 20 months, respectively.CONCLUSIONMost of the patients presented in advanced stage of the disease and have poor outcome. Delay in diagnosis and improper management before registering in tertiary cancer center and lack of tertiary care facilities are the root causes of poor outcomes. The general population and primary care physicians need to be made aware of OC symptoms.

Comparison of Definitive Cervical Cancer Management With Chemotherapy and Radiation Between Two Centers With Variable Resources and Opportunities for Improved Treatment

PURPOSE Cervical cancer remains a major health challenge in low- to middle-income countries. We present the experiences of two centers practicing in variable resource environments to determine predictors of improved radiochemotherapy treatment. METHODS AND MATERIALS This comparative review describes cervical cancer presentation and treatment with concurrent chemoradiotherapy with high-dose-rate brachytherapy between 2014 and 2017 at the National Radiotherapy Oncology and Nuclear Medicine Center (NRONMC) in Korle-Bu Teaching Hospital, Accra, Ghana, and Moffitt Cancer Center (MCC), Tampa, FL. RESULTS Median follow-up for this study was 16.9 months. NRONMC patients presented with predominantly stage III disease (42% v 16%; P = .002). MCC patients received para-aortic node irradiation (16%) and interstitial brachytherapy implants (19%). Median treatment duration was longer for NRONMC patients compared with MCC patients (59 v 52 days; P < .0001), and treatment duration ≥ 55 days predicted worse survival on multivariable analysis (MVA; P = .02). Stage ≥ III disease predicted poorer local control on MVA. There was a difference in local control among patients with stage III disease (58% v 91%; P = .03) but not in survival between MCC and NRONMC. No significant difference in local control was observed for stage IB, IIA, and IIB disease. CONCLUSION Although there were significant differences in disease presentation between the two centers, treatment outcomes were similar for patients with early-stage disease. Longer treatment duration and stage ≥ III disease predicted poor outcomes.

Urban Poor Community Settings' Knowledge and Screening Practices for Cervical Cancer in Ibadan, Nigeria

PURPOSE This study investigated knowledge and screening practices for cervical cancer among two urban poor community settings in Ibadan, Nigeria. METHODS A cross-sectional design was used. ODK tool was used to collect quantitative data among a sample size of 500 respondents. Data were analyzed using IBM SPSS version 21 for descriptive and inferential statistics. Scores for knowledge were on a scale of 0-39 points (0-18 low, 19-23 fair, and 24-39 high knowledge). RESULTS A majority of respondents (77.2%) had low knowledge of cervical cancer and were not aware (93.6%) of the Papanicolaou test (Pap smear test) or cervical cancer screening (91.2%). Very few women (10%) were aware of the human papillomavirus vaccine for the prevention of cervical cancer, 4% had been screened with the Papanicolaou test, and one woman (0.3%) with visual inspection with acetic acid. Four (1.1%) women had taken human papillomavirus vaccine before. CONCLUSION The findings of this study have underscored a necessity for increased awareness creation through health promotion interventions and strategies to alleviate low knowledge, prevention, and screening practices for cervical cancer in poor community settings in Nigeria.

Erratum: Distribution and Types of High-Risk Human Papillomavirus Genotypes and Associated Cervical Neoplastic Lesions in Women Living With HIV Infection in Jos Nigeria

Germline Mutational Landscape and Novel Targetable RAD51D Variant in Chinese Patients With Ovarian Cancer

PURPOSE Genetic variants of ovarian cancer (OV) show ethnic differences, but data from the Chinese population are still insufficient. Here, we elucidate the inheritance landscape in Chinese patients with OV and examine the functional implications of a Chinese-enriched RAD51D variant. METHODS Between 2015 and 2018, 373 consecutive patients with OV were prospectively enrolled. Variants of BRCA1/2, other homologous recombination repair (HRR) genes, and DNA mismatch repair (MMR) genes were analyzed using next-generation sequencing. An enriched RAD51D variant was identified, and its functional effects were examined using Cell Counting Kit-8, colony formation, transwell migration, and drug sensitivity assays. RESULTS Overall, 31.1% (116/373) of patients had at least one pathogenic or likely pathogenic germline variant. BRCA1 and BRCA2 accounted for 16.09% and 5.36%, respectively, with one patient having both variants. In addition, 32 (8.58%) patients carried other HRR gene variants, whereas three (0.8%) patients had MMR gene variants. The RAD51D variant ranked third (8/373, 2.1%), and its rate was much higher than that in other populations. Remarkably, all eight patients harbored the RAD51D K91fs variant (c.270_271dup, p.Lys91Ilefs*13) and demonstrated satisfactory platinum response and favorable prognosis. This variant confers enhanced sensitivity to poly (ADP-ribose) polymerase inhibitors in OV cells. However, the effects on platinum sensitivity were inconsistent across different cell lines. Against the background of the TP53 variant, RAD51D K91fs variant showed increased sensitivity to cisplatin. CONCLUSION Our study revealed the inheritance landscape of OV and identified an enriched RAD51D variant in Chinese patients with OV. This can serve as an important reference for OV management and a potential therapeutic target.

Knowledge, Attitudes, and Health-Seeking Behavior for Cervical, Breast, and Oral Cancers Among Women in Jashore, Bangladesh: A Cross-Sectional Study

PURPOSE This study aimed to assess cancer-related knowledge, attitudes, screening behaviors, and willingness to engage in community-based screening for cervical, breast, and oral cancers among women in rural Bangladesh, with the goal of informing the design of a scalable, national cancer screening strategy. METHODS A cross-sectional survey was conducted among 1,046 eligible women (age ≥ 30 years or married ≥ 10 years) in Nawly village, Jashore, Bangladesh. Trained interviewers administered a structured questionnaire assessing sociodemographics, cancer knowledge, attitudes, screening behaviors, and willingness to participate in organized screening. Descriptive statistics and multivariate logistic regression models identified predictors of knowledge, participation, and willingness. RESULTS Although 75.4% of women were aware of cervical cancer, only 28.3% correctly identified screening intervals. Awareness of breast and oral cancer screening was lower (11.5% and 6.2%, respectively). Participation in cervical cancer screening was 18.2%, and <1% for breast or oral cancer. However, willingness to participate in future community-based screening was high (>89% across all cancer types). Higher education and income were significantly associated with better knowledge and increased screening participation. Fear and misconceptions were the most common barriers among those unwilling to participate. CONCLUSION Despite limited screening uptake, there is strong community readiness for organized cancer screening. These findings underscore the need for tailored education campaigns and scalable, community-based programs to enhance early cancer detection in low-resource settings such as Bangladesh.

Evaluation of Quality Indicators for Radiation Therapy of Cervical Cancer: Experience From a Tertiary Cancer Center in Nepal

PURPOSE Cervical cancer is the second commonest cancer among women in Nepal. The objective of the study was to evaluate the quality indicators (QIs) in radiotherapy management of cervical carcinoma and establishment of organizational priorities feasible in our setting. METHODS The retrospective study included 83 patients with locally advanced cervical carcinoma who had taken treatment at Bhaktapur Cancer Hospital in 1 year. Participants were selected based on convenience sampling. All 19 QIs in cervical cancer management according to The European Society of Gynecological Oncology (ESGO)/European Society for Radiotherapy and Oncology (ESTRO) were chosen for assessment. These QIs were calculated for all patients and compared with the ESGO/ESTRO standard target. Frequencies and percentages were calculated. Binomial 95% of the rates for QI adherence was also calculated for each QI. RESULTS Of the 19 QIs, very high adherence rates were observed in QIs associated with brachytherapy like Treatment with brachytherapy boost (97.59%), Imaging for Image guided Adaptive Brachytherapy (100%), and Brachytherapy after the patient has received a total EBRT dose ≥36 Gy (100%). Compliance was good for patients receiving primary chemo-radiotherapy (86.74%) and center treating adequate cases (100%). Very low adherence rates were observed for pretreatment work-up (0%), use of intensity modulated radiotherapy (2.4%), on-board image guided radiotherapy (0%), clinical trial participation (0%), and follow-up program and sexual rehabilitation (0%). Multidisciplinary team meeting discussion of cases (48.19%), use of interstitial brachytherapy when required (12.34%), and EBRT dose of 45 Gy/25 fractions (27.71%) also had a low adherence rate. CONCLUSION The study highlighted rates of compliance to cervical radiotherapy QIs in our hospital. Low adherence to various QIs was identified. On the basis of these findings, mitigating strategies could be planned at our center.

Adoption and Implementation of Affordable Cancer Technologies in El Salvador: Identifying Implementation Strategies for Successful Cervical Cancer Prevention in Resource-Limited Settings

As part of the affordable cancer technology program, our team developed and tested a portable thermal ablation (TA) cervical precancer treatment. This research helped support subsequent implementation of the technology in El Salvador. Here, we review successful implementation strategies deployed during the process and point to challenges and implications for other low- and middle-income countries (LMICs). We use the exploration, preparation, implementation, and sustainment framework to guide the discussion and identify associated implementation strategies used during each phase. Significant strategies were the development and maintenance of multi-actor partnerships and accessing new funding to introduce innovations to the country. In this case, planning for implementation began before the decision to adopt TA. The case of El Salvador highlights the need for such pragmatic approaches to shorten the time between scientific research and clinical practice in LMICs. The impact of these efforts has been significant: El Salvador has gone from one of the countries with the lowest cervical cancer screening rates in the region to one that can potentially meet elimination targets in the coming decades. This experience can serve as a blueprint for cervical cancer control efforts in other LMICs.

Real-World Cervical Cancer Screening Uptake and Predictors of Visual Inspection With Acetic Acid Positivity Among Women Living With HIV in Care Programs in Western Kenya

PURPOSE To achieve the WHO cervical cancer elimination targets, countries globally must achieve 70% cervical cancer screening (CCS) coverage. We evaluated CCS uptake and predictors of screening positive at two public HIV care programs in western Kenya. METHODS From October 2007 to February 2019, data from the Family AIDS Care and Education Services (FACES) and Academic Model Providing Access to Healthcare (AMPATH) programs in western Kenya were analyzed. The study population included women age 18-65 years enrolled in HIV care. Screening uptake was calculated annually and overall, determining the proportion of eligible women screened. Multivariate logistic regression assessed predictors of positive screening outcomes. RESULTS There were 57,298 women living with HIV (WLWHIV) eligible for CCS across both programs during the study period. The mean age was 31.4 years (IQR, 25.9-37.8), and 39% were on antiretroviral therapy (ART) at the first CCS-eligible visit. Of all eligible women, 29.4% (95% CI, 29.1 to 29.8) underwent CCS during the study period, 27.0% (95% CI, 26.5 to 27.4) in the AMPATH program, and 35.6% (95% CI, 34.9 to 36.4) in the FACES program. Annual screening uptake varied greatly in both programs, with coverage as low as 1% of eligible WLWHIV during specific years. Age at first screening, CD4 count within 90 days of screening, current use of ART, and program (AMPATH v FACES) were each statistically significant predictors of positive screening. CONCLUSION CCS uptake at two large HIV care programs in Kenya fell short of the WHO's 70% screening target. Screening rates varied significantly on the basis of the availability of funding specific to CCS, reflecting the limitations of vertical funding programs.

Implementation of Brachytherapy for Patients With Cervical Cancer in Ethiopia: A 3-Year Practice Report

PURPOSE Although cervical cancer is the second most commonly diagnosed cancer in Ethiopia, brachytherapy (BT) was not a component in patient treatment until 2015. The purpose of this study was to identify the patterns of utilization as well as to describe the practice of BT in Ethiopia. MATERIALS AND METHODS A retrospective descriptive data analysis of 138 patients with cervical cancer treated with a curative potential using BT from 2015 to 2018 at Tikur Anbassa Specialized Hospital, which housed the only BT facility in Ethiopia during the study period. RESULTS During the first 3-year period of BT service commencement, each year n = 37, n = 36, and n = 65 patients with cervical cancer were treated, respectively, with curative intention treatment. The median age of these 138 patients was 50 years (range, 22-75). All the patients were in International Federation of Gynecology and Obstetrics stage Ib–IIIb group, and stage IIb (66.4%) was the predominant. Majority (79%) of the patients were treated primarily with radiotherapy (RT), while 21% received RT after surgery. More than half of these patients (62%) received a total RT dose of 82 Gy in equivalent dose in 2 Gy fractions (EQD2), while the rest received a dose ranging from 76 to 86 Gy. Concurrent cisplatin with RT was given only for 36% of the patients for undocumented reasons. The overall treatment time including both external-beam RT and BT was greater than 8 weeks in 21% of the patients. CONCLUSION The utilization of BT service increased gradually and BT enabled the delivery of a higher RT dose to patients with cervical cancer (mostly stage IIB). However, there was protracted treatment duration and low concurrent chemotherapy utilization.

Cancer Screening in the Coronavirus Pandemic Era: Adjusting to a New Situation

PURPOSE The coronavirus-induced pandemic has put great pressure on health systems worldwide. Nonemergency health services, such as cancer screening, have been scaled down or withheld as a result of travel restrictions and resources being redirected to manage the pandemic. The present article discusses the challenges to cancer screening implementation in the pandemic environment, suggesting ways to optimize services for breast, cervical, and colorectal cancer screening. METHODS The manuscript was drafted by a team of public health specialists with expertise in implementation and monitoring of cancer screening. A scoping review of literature revealed the lack of comprehensive guidance on continuation of cancer screening in the midst of waxing and waning of infection. The recommendations in the present article were based on the advisories issued by different health agencies and professional bodies and the authors' understanding of the best practices to maintain quality-assured cancer screening. RESULTS A well-coordinated approach is required to ensure that essential health services such as cancer management are maintained and elective services are not threatened, especially because of resource constraints. In the context of cancer screening, a few changes in invitation strategies, screening and management protocols and program governance need to be considered to fit into the new normal situation. Restoring public trust in providing efficient and safe services should be one of the key mandates for screening program reorganization. This may be a good opportunity to introduce innovations (eg, telehealth) and consider de-implementing non–evidence-based practices. It is necessary to consider increased spending on primary health care and incorporating screening services in basic health package. CONCLUSION The article provides guidance on reorganization of screening policies, governance, implementation, and program monitoring.

Prevalence of Potentially Pathogenic Germline Variants Among Adult Patients in the Philippines With Solid Malignancies Who Underwent Tumor Genomic Profiling

PURPOSE In high-income countries, 2%-10% of tumor genomic profiling (TGP) reports reveal incidental pathogenic germline variants. A third of these patients would not qualify for genetic testing on the basis of current guidelines. Our study determined the prevalence of potentially pathogenic germline variants (PPGVs) in TGP results of adult patients with solid malignancies in the Philippines. METHODS Annotated reports of patients with solid cancers who underwent TGP using FoundationOne or FoundationOne Heme between January 2021 and July 2023 were reviewed. PPGV criteria include having a variant allele frequency of >30% and were categorized as (1) high penetrance gene (HP), founder variant (FV), or variant associated with clinical presentation (VA). Pathogenicity was crosschecked through the ClinVar database. RESULTS Of 446 patients, 13 PPGV variants were found in 50 (11.2%) patients at a median age of 60.5 years. Of them, 28 (56%) had HP ( BRCA1, BRCA2, MSH2, MSH6, MLH1, RAD51C, RAD51D), 25 (50%) patients had VA ( APC, SMAD4, CDH1, CDKN2A, PTEN), and two patients with lung cancer had a FV ( EGFR p.Thr790Met). Six patients had more than one PPGV. PPGVs were primarily found in patients with colorectal (42% of 50 patients with PPGVs), breast (16%), ovarian (6%), and lung (6%) cancer ( P < .001). HP genes were mostly found in female patients (71.4%; P = .03). CONCLUSION With a PPGV prevalence of 11% in this study, it is important to recognize PPGVs as it can prompt genetic counseling and confirmatory germline testing.

Feasibility and Clinical Acceptability of Automation-Assisted 3D Conformal Radiotherapy Planning for Patients With Cervical Cancer in a Resource-Constrained Setting

Automation may enable high-quality cervical cancer radiation on shorter treatment planning timelines.

Emergency Embolization of Pelvic Vessels in Patients With Locally Advanced Cervical Cancer and Massive Vaginal Bleeding: A Case Series in a Latin American Oncological Center

PURPOSE Locally advanced cervical cancer may present with uncontrollable vaginal bleeding in up to 70% of cases. Pelvic vessel embolization has been used as an urgent maneuver for achieving fast hemostatic control. This report describes outcomes of selective pelvic vessel embolization in patients with severe bleeding due to a locally advanced cervical cancer. METHODS In this retrospective study, technical aspects, clinical variables, and bleeding-related morbidity were described. The frequency of recurrent disease and the vital status at 1 year of follow-up were determined. Analysis was performed with statistical software R, version 3.6.2. The setting was Instituto Nacional de Cancerología- Bogotá, Colombia, between January 2009 and July 2017. RESULTS A total of 47 patients were included. Median age was 44 years (range, 26-70 years). The pre-embolization median hemoglobin level was 7.9 g/dL (range, 5.0-11.3 g/dL). Blood transfusions were administered to 41 women (87.2%). Bleeding control was achieved in 95.7% of cases in the first 24 hours after the embolization. There were no major complications. In 17 cases (36.2%), minor complications were reported; the most common was pelvic pain. In 17.1% of cases, a second embolization was required. After 12 months of follow-up, 27.7% of patients were alive without disease, 44.7% were alive with disease, and 25.5% of them have died of cervical cancer progression. CONCLUSION Selective pelvic vessel embolization is a useful alternative in patients with locally advanced cervical cancer and life-threatening bleeding. Its impact on recurrent disease and death due to oncologic cause is not clear.

Impact of Global Enrollment on Race, Ethnicity, and Age Representation in Pivotal Gynecologic Cancer Trials Leading to US Food and Drug Administration Drug Approvals

PURPOSE To evaluate the impact of international enrollment in landmark gynecologic cancer (Gyn-Ca) trials that supported the US Food and Drug Administration (FDA) drug approvals. METHODS We examined the FDA drug approval database for approved Gyn-Ca agents between January 2014 and June 2024. We then extracted clinical trial identifiers supporting these approvals using FDA safety labels. Expected enrollment was calculated using gynecologic disease site incidence data from the US Cancer Statistics Program and compared with actual trial enrollment reported on ClinicalTrials.gov. RESULTS From 2014 to 2024, 30 Gyn-Ca trials supporting 28 FDA approvals were conducted in US/international (86.7%), international-only (10%), and US-only sites (3.3%) and enrolled 15,294 patients, with 14,053 remaining (74.0% White, 4.1% Black, 12.7% Asian, 8.7% other) after screening for trials not reporting race. Black (–11.0%; P < .0001), Hispanic/Latino (–3.5%; P < .0001), and elderly (–12.6%; P < .0001) participants were under-represented, whereas Asians (+6.8%; P < .0001) were over-represented. Asian (18.3% v 3.5% in trials with or without East Asian sites; odds ratio [OR], 6.19 [95% CI, 5.29 to 7.25]; P < .0001) and Hispanic/Latino (18.6% v 4.6% in trials with or without South American sites; OR, 4.75 [95% CI, 4.00 to 5.63]; P < .0001) enrollment was higher in trials that included East Asian and South American sites, respectively. Black enrollment did not improve despite trials including recruitment in Africa (3.2% v 4.1% Black enrollment in trials with or without African sites; OR, 0.83 [95% CI, 0.38 to 1.83]; P = .53). CONCLUSION Black, Hispanic/Latino, and elderly patients were under-represented in pivotal Gyn-Ca trials, whereas Asian patients were over-represented, compared with expected enrollment proportions. Postmarketing studies on under-represented groups should be considered to assess drug efficacy and safety in these populations.

Smartphone-Enhanced Training, QA, Monitoring, and Evaluation of a Platform for Secondary Prevention of Cervical Cancer: Opportunities and Challenges to Implementation in Tanzania

PURPOSE Until human papillomavirus (HPV)–based cervical screening is more affordable and widely available, visual inspection with acetic acid (VIA) is recommended by the WHO for screening in lower-resource settings. Visual inspection will still be required to assess the cervix for women whose screening is positive for high-risk HPV. However, the quality of VIA can vary widely, and it is difficult to maintain a well-trained cadre of providers. We developed a smartphone-enhanced VIA platform (SEVIA) for real-time secure sharing of cervical images for remote supportive supervision, data monitoring, and evaluation. METHODS We assessed programmatic outcomes so that findings could be translated into routine care in the Tanzania National Cervical Cancer Prevention Program. We compared VIA positivity rates (for HIV-positive and HIV-negative women) before and after implementation. We collected demographic, diagnostic, treatment, and loss-to-follow-up data. RESULTS From July 2016 to June 2017, 10,545 women were screened using SEVIA at 24 health facilities across 5 regions of Tanzania. In the first 6 months of implementation, screening quality increased significantly from the baseline rate in the prior year, with a well-trained cadre of more than 50 health providers who “graduated” from the supportive-supervision training model. However, losses to follow-up for women referred for further evaluation or to a higher level of care were considerable. CONCLUSION The SEVIA platform is a feasible, quality improvement, mobile health intervention that can be integrated into a national cervical screening program. Our model demonstrates potential for scalability. As HPV screening becomes more affordable, the platform can be used for visual assessment of the cervix to determine amenability for same-day ablative therapy and/or as a secondary triage step, if needed.

Evaluation of a Chip-Based, Point-of-Care, Portable, Real-Time Micro PCR Analyzer for the Detection of High-Risk Human Papillomavirus in Uterine Cervix in India

PURPOSE Currently available human papillomavirus (HPV) detection devices are expensive, requiring a continuous power supply, high-priced reagents, skilled laboratory personnel, and infrastructure. These make it difficult to implement primary HPV screening in high-risk (HR) populations, particularly in low-income settings such as in India. The objective of our study was to evaluate the diagnostic performance of a point-of-care, portable, battery-operated device called Truenat, which detects 4 HR HPV genotypes (16, 18, 31, and 45), as a potentially cost-effective alternative to conventional HPV diagnostic tests. PATIENTS AND METHODS This was a single-site, blinded, cross-sectional study that evaluated the performance of the Trunat HPV-HR using cervical samples collected from nonpregnant women > 30 years old via consecutive sampling. The comparison was conducted against the Hybrid Capture 2 (HC2) method. All the positive samples were validated by 14 Real-TM Quant Kit. RESULTS Of 615 cervical samples, the HR-HPV DNA test was positive in 78 women (12.7%) by HC2 and in 49 (8%) by Truenat. With the consideration of limited genotype inclusivity, the sensitivity and specificity of Truenat HPV-HR were 97.7% and 98.9%, respectively. CONCLUSION The performance of Truenat HPV-HR test was comparable to that of HC2 in the 4 HPV genotypes and would be appropriate to consider for use in primary HR cervical cancer screening and particularly in low-income settings.

Modeling for Predictors of Knowledge Score on Etiology and Prevention Strategies for Cervical Cancer Among Women of Reproductive Age in Ibadan

PURPOSE Poor knowledge regarding cervical cancer in at-risk populations directly affects health-seeking behavior and is associated with high mortality among women with cervical cancer. This study aims to evaluate the knowledge of women regarding the causes, risk factors, and prevention strategies of cervical cancer. METHODS A multistage cross-sectional study of 1,002 women of reproductive age (18-49 years) in Ibadan was conducted. Knowledge of cervical cancer risk causes and prevention strategies was assessed using 13 and 9 question items, respectively. The knowledge score was graded as 0 (no knowledge), 1-4 (poor knowledge), or ≥ 5 (good knowledge). The proportional or partial proportional odds model was used to fit 3 models using the forward stepwise selection. All analysis was performed using Stata 15.0 (Stata Corp, College Station, TX). RESULTS The median age of participants was 29 years (interquartile range [IQR], 23-35 years). The median knowledge scores of participants on causes and prevention strategies of cervical cancer were 3 (IQR, 0-4) and 3 (IQR, 0-5), respectively. The assessment of knowledge on causes and prevention strategies for cervical cancer revealed that having multiple sexual partners and no previous opportunity for counseling on cervical cancer screening were factors associated with lower odds of knowledge. CONCLUSION The knowledge of women about the risk factors, causes, and prevention strategies of cervical cancer was poor. It is worrisome that poor knowledge was common among women with potential demographic risk factors for cervical cancer. We recommend innovative community mobilization to improve women’s knowledge of the risk factors associated with cervical cancer and prevention strategies.

Feasibility, Acceptability, and Efficacy of a Community Health Worker–Driven Approach to Screen Hard-to-Reach Periurban Women Using Self-Sampled HPV Detection Test in India

PURPOSE Detection of high-risk human papillomavirus (HPV) in self-collected vaginal samples can significantly improve participation of hard-to-reach women; however, the implementation of such an approach in a real-life setting, especially in countries with limited resources, has certain challenges. Our study aimed to evaluate the feasibility, acceptability, and efficacy of implementing an HPV self-sampling–based approach to screen a socioeconomically disadvantaged, unscreened population with support from community health workers (CHWs) for community mobilization, counseling, and navigation. Different triaging options for HPV-positive women were also assessed. METHODS Women age 30 to 65 years from low socioeconomic periurban areas who had never been screened before were motivated by CHWs to attend local community centers and provide self-collected vaginal samples for careHPV testing. Screen-positive women were informed and navigated by CHWs to attend colposcopy clinics where cervical biopsy and same-day ablative treatment were offered. RESULTS Women readily accepted to provide self-collected samples after counseling by CHWs. Screen positivity was 6.4%, and CHWs successfully navigated 65% of HPV-positive women to colposcopy. Cervical intraepithelial neoplasia (CIN) 2+ detection rate was 9.7 per 1,000 women screened. The HPV test had a positive predictive value of 15.3% to detect CIN 2+ lesions. Triage using visual inspection with acetic acid significantly improved the positive predictive value (49.5% to detect CIN 2+), but missed a significant number of CIN 2+ lesions. Colposcopy sensitivity was also suboptimal. Of 51 women with lesions, 80% underwent ablative treatment and the majority accepted same-day treatment. CONCLUSION CHW-driven self-sampling for HPV testing is feasible, well-accepted, and effective for screening unscreened hard-to-reach women. The screen-and-treat approach can ensure strong linkage between screening and treatment.

Assessment of Knowledge and Screening in Oral, Breast, and Cervical Cancer in the Population of the Northeast Region of India

PURPOSE The burden of cancer is increasing globally, with poor outcomes in terms of morbidity and mortality in patients, especially in low- and middle-income countries. Lack of awareness of the risk factors, symptoms, and signs of common cancers in addition to inadequate cancer prevention programs at the community level are a major hindrance to the early detection of cancer. METHODS A cross-sectional study was conducted in the North East Region (NER) of India, with a sample population of 1,400 participants from Assam (n = 1,000), Meghalaya (n = 200), and Nagaland (n = 200). The questionnaire developed for the study consisted of sociodemographic profile, knowledge about cancer (oral, breast, and cervical), its warning signs, risk factors, and attitude toward cancer screening. Statistical analysis was performed using STATA version 13.0. RESULTS Among all the participants, 59% had heard about oral cancer, 50% about breast cancer, and 31% about cervical cancer. A limited understanding of risk factors, symptoms, and signs was reported for oral cancer (45%), breast cancer (54%), and cervical cancer (63%). A total of 34% of participants were aware of cancer screening. Among those who were aware of cancer screening, only six people had undergone any form of cancer screening, and 71% cited media as the major source of information. CONCLUSION The level of cancer awareness is low in the NER. A multipronged approach is needed with assistance from government and nongovernment organizations for training, providing adequate human resources and equipment, and developing cancer screening infrastructure. This needs to be coupled with mass media communication and interpersonal communication through frontline health workers.

Extent and Predictors of Delays in Diagnosis of Cervical Cancer in Addis Ababa, Ethiopia: A Population-Based Prospective Study

PURPOSE A substantial proportion of cervical cancers are diagnosed at advanced stage in Ethiopia. Therefore, the aim of this study was to determine the extent and predictors of delays in cervical cancer diagnosis in Addis Ababa. PATIENTS AND METHODS We prospectively recruited 231 patients with cervical cancer diagnosed from January 1, 2017, to June 30, 2018, in 7 health facilities in Addis Ababa, representing 99% of all cervical cancers recorded in the Addis Ababa population-based cancer registry. A structured questionnaire on patients’ experience was administered face to face by trained interviewers. Health-seeking intervals > 90 days (date from recognition of symptoms to medical consultation) and diagnostic intervals > 30 days (dates from medical consultation to diagnostic confirmation) were categorized as delayed. Factors associated with these delays were assessed using multivariable binary logistic regression models. RESULTS The median health-seeking and diagnostic intervals for patients with cervical cancer in Addis Ababa were 10 and 97 days, respectively. Approximately one quarter of the patients were delayed in seeking medical consultation, and three fourths of the patients had delayed diagnostic confirmation. Factors associated with health-seeking delays included poor cervical cancer awareness, practicing of religious rituals, and waiting for additional symptoms before visiting a health facility. Factors associated with diagnostic delays included first contact with primary health care units and visits to ≥ 4 different health facilities before diagnosis. CONCLUSION A considerable proportion of patients with cervical cancer in Addis Ababa have delays in seeking medical care and diagnostic conformation. These findings reinforce the need for programs to enhance awareness about cervical cancer signs and symptoms and the importance of early diagnosis in the community and among health care providers.

Increasing Cervical Cancer Incidence in Rural Eastern Cape Province of South Africa From 1998 to 2012: A Population-Based Cancer Registry Study

PURPOSE In this study, we aimed to investigate trends in the age-standardized and age-specific incidence rates in two distinct regions (the northern and southern areas) of South Africa covered by a population-based cancer registry. In addition, trends in coverage of the cervical cancer screening program were assessed using routine health service data. METHODS Occurrences (topography C53.0-C53.9) for the period 1998-2012 were extracted from a cancer registry database from which basic descriptive statistics and frequencies were analyzed for all variables using CanReg4. Trends over time were estimated using a direct standardization method and world standard population as a reference. Screening coverage annualized figures for women age ≥ 30 years by sub–health district were extracted from the District Health Information System. RESULTS In the northern area, annual age-standardized incidence rates per 100,000 women increased from 24.0 (95% CI, 21.1 to 27.0) in 1998-2002 to 39.0 (95% CI, 35.6 to 42.5) in 2008-2012, with a screening coverage rate of 15% by 2012. In contrast, no increase was observed in incidence in the southern area, with rates of 20.0 (95% CI, 18.5 to 21.4) in 1998-2002 and 18.8 (95% CI, 16.2 to 21.4) in 2008-2012, and the southern area had a higher screening coverage of 41% in 2012. Overall, the percentage distribution of stage at diagnosis showed that 28.5% of occurrences were diagnosed at disease stages I and II and 35%, at III and IV; 36% had with missing stage information (2003-2012). In 77% of occurrences, a histologically verified diagnosis was made, compared with only 12.3% by cytology. CONCLUSION This study has demonstrated an almost two-fold increase in the incidence rate in the northern area but little change in the southern area of the cancer registry.

Patient Advocacy Approaches to Improving Care for Breast and Cervical Cancer in East and Southern Africa

PURPOSE Breast and cervical cancer are the most common cancers among women in East and Southern Africa, where mortality remains high because of late diagnosis and limited access to treatment. We explored local approaches to breast and cervical cancer advocacy to identify the most pressing issues and opportunities for increasing the impact of civil society activities in the region. METHODS Focus group discussions were conducted with participants of the 2016 Women’s Empowerment Cancer Advocacy Network (WE CAN) Summit in Nairobi, Kenya. Discussions were audio-recorded, transcribed, coded, and analyzed for emergent themes. Results were presented to participants of 2019 WE CAN summit for cross-validation. RESULTS Four focus group discussions were conducted with 50 participants. Thirty-six (70%) identified as advocates, 30 (59%) as cancer survivors, 14 (27%) as nongovernmental organization representatives, 13 (25%) as researchers, 4 (8%) as clinicians, and 6 (8%) as policymakers. Although most participants focused on cancer awareness and screening/early detection, some noted that treatment was often unavailable and advocated for a broader strategy to improving access to care. Challenges to designing and implementing such a strategy included knowledge gaps in addressing late diagnosis and access to care, difficulty collaborating with like-minded organizations, approaching policymakers, and addressing treatment financing. Cancer coalitions, although rare, were crucial to building collaborations with ministries of health, policymakers, and international organizations that advanced breast and cervical cancer care. CONCLUSION Participants indicated that they would benefit from additional training about resource-appropriate best practices for improving breast and cervical cancer care and outcomes. Coalition-building and collaborations, including with oncologists and other medical professionals involved in cancer care, were crucial to leveraging limited resources, sharing lessons learned, and developing local solutions to common challenges.

Five-Year Cancer Epidemiology at the National Referral Hospital: Hospital-Based Cancer Registry Data in Indonesia

PURPOSE In 2016, there were 1,308,061 cases of cancer being treated in Indonesia, with 2.2 trillion rupiahs spent, amounting to $486,960,633 in US dollars (purchasing power parity 2016). The high burden of cancers in Indonesia requires a valid data collection to inform future cancer-related policies. The purpose of this study is to report cancer epidemiological data from 2008 to 2012 based on Hospital-Based Cancer Registry (HBCR) data from Cipto Mangunkusumo Hospital, Indonesia. METHODS This was a descriptive study with cross-sectional design. Data were collected from Cipto Mangunkusumo Hospital HBCR 2008-2012. Demographical, diagnostic, stages of cancer, and histopathological types of cancer data were extracted. RESULTS After screening, 18,216 cases were included. A total of 12,438 patients were older than 39 years of age (68.3%), with a female-to-male ratio of 9:5. Most patients have cancers at advanced stages (stages III and IV, 10.2%). The most common sites of cancer were cervix uteri (2,878 cases, 15.8%), breast (2,459 cases, 13.5%), hematopoietic and reticuloendothelial systems (1,422 cases, 7.8%), nasopharynx (1,338 cases, 7.4%), and lymph nodes (1,104 cases, 6.1%). CONCLUSION From this HBCR, cancer incidence in female was almost twice the incidence in male, largely because of the burden of cervical and breast cancers. The cervix uteri as one of the top five cancer sites based on this HBCR, 2008-2012, are still approximately consistent with Global Cancer Incidence, Mortality and Prevalence 2018, which portrayed that Indonesia has been severely afflicted by cervical cancer cases more than any other Association of Southeast Asian Nations countries. The HBCR could serve as a robust database of epidemiological data for cancer cases in Indonesia.

Pazopanib and Oral Cyclophosphamide in Women With Platinum-Resistant or -Refractory Epithelial Ovarian Cancer

PURPOSE Women with recurrent, multiply-treated epithelial ovarian cancer (EOC) have unfavorable prognosis with limited treatment options after failure of platinum-based regimens. We report here a retrospective analysis of women with recurrent, platinum-resistant EOC treated with an oral regimen of pazopanib and cyclophosphamide. PATIENTS AND METHODS Women with recurrent platinum-resistant or -refractory EOC were treated with pazopanib (600 mg orally daily in 2 divided doses, 400 and 200 mg) and cyclophosphamide (50 mg orally daily for 21 days every 28 days) until disease progression or unacceptable toxicity. RESULTS Twenty patients (17 with platinum-resistant and 3 with platinum-refractory disease) were treated between April 2014 and April 2018. Patients had a median age of 52 years (range, 40-60 years) and median of 4 previous lines of chemotherapy (range, 2-8 previous lines), including 3 patients with progressive disease on bevacizumab. Patients received a median of 6 cycles (range, 2-48 cycles) of pazopanib and cyclophosphamide, with best responses of partial response in 9 patients (45%, including 1 of 3 patients treated previously with bevacizumab), stable disease in 6 patients (30%), and disease progression in 5 patients (25%). The median progression-free survival time was 5.5 months, and median overall survival was 9.5 months. Common adverse events (grade 3 or 4) were fatigue (25%), diarrhea (15%), hand-foot syndrome (10%), mucositis (10%), transaminitis (5%), and hypertension (5%). Dose reduction as a result of toxicity was required in 14 patients (70%), and no patient stopped treatment as a result of toxicity. CONCLUSION Pazopanib plus oral cyclophosphamide is a well-tolerated regimen with clinically relevant benefit in patients with platinum-resistant or -refractory EOC.

Recommendations for Advancing the Diagnosis and Management of Hereditary Breast and Ovarian Cancer in Brazil

PURPOSEThe objective of this review was to address the barriers limiting access to genetic cancer risk assessment and genetic testing for individuals with suspected hereditary breast and ovarian cancer (HBOC) through a review of the diagnosis and management steps of HBOC.METHODSA selected panel of Brazilian experts in fields related to HBOC was provided with a series of relevant questions to address before the multiday conference. During this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion, until a consensus was achieved.RESULTSThe authors propose specific and realistic recommendations for improving access to early diagnosis, risk management, and cancer care of HBOC specific to Brazil. Moreover, in creating these recommendations, the authors strived to address all the barriers and impediments mentioned in this article.CONCLUSIONThere is a great need to expand hereditary cancer testing and counseling in Brazil, and changing current policies is essential to accomplishing this goal. Increased knowledge and awareness, together with regulatory actions to increase access to this technology, have the potential to improve patient care and prevention and treatment efforts for patients with cancer across the country.

A Retrospective Analysis of the Impact of HIV Infection on Outcomes of Locally Advanced Cervical Cancers Treated With Either Conventional or Hypofractionated Radiotherapy: The Uganda Experience

PURPOSE We annually treat more than 800 new patients with cervical cancer, where the majority (approximately 60%) have locally advanced disease and approximately 40% of them are infected with HIV. To optimally care for this large number of patients in low-income settings is difficult. From July 2011, we started using 45.0 Gy/15# hypofractionated radiotherapy (HFRT) as a substitute to 50.0 Gy/25# conventional fractionated radiotherapy (CFRT), for the treatment of locally advanced cervical cancer (LACC). This study aims at comparing the 5-year treatment outcomes between patients with LACC, known HIV serostatus, and treated with either CFRT or HFRT. METHODS A retrospective study was conducted according to demographic/clinical data, radiotherapy fractionations, and outcomes. Factors considered were FIGO stages IIB-IIIB, known HIV serostatus, and had completed external-beam radiotherapy and intracavitary brachytherapy. The primary end point was overall survival; the secondary end points were toxicity and compliance. RESULTS The study included 221 patients. Squamous cell carcinomas were 95.1% and adenocarcinomas 2.3%. The median age was 45.0 (interquartile range, 38.0-52.0) years. Stages IIB, IIIA, and IIIB were 38.9%, 6.3%, and 54.8%, respectively. HIV-positive and HIV-negative were 87 (39.4%) and 134 (60.6%), respectively. Chemoradiation was administered in 100 (45.2%), and 52 (52.0%) completed chemotherapy. CFRT/HFRT were 116 (52.5%)/105 (47.5%). At 24 months, the overall response was 54.1% for HIV-negative compared with 45.0% for HIV-positive ( P value .262). There was no significant differences in acute/late toxicity grades ≥ 2 for HIV-negative/positive treated with HFRT/CFRT. At 60 months, the survival probabilities were 45.7% and 27.7% for HIV-negative and HIV-positive treated with CFRT ( P value = .006), whereas it was 44.2% and 30.7% for HIV-negative and HIV-positive treated with HFRT ( P value = .048), respectively. CONCLUSION For the treatment of LACC with known HIV serology, there was no significant statistical difference in terms of response, toxicity, and compliance between CFRT and HFRT. However, the difference in overall survival between HIV-negative and HIV-positive was significant.

Prevalence and Subtype Distribution of High-Risk Human Papillomavirus Among Women Presenting for Cervical Cancer Screening at Karanda Mission Hospital

PURPOSE High-risk human papillomaviruses (hrHPV) are the primary cause of cervical cancer. Human papillomavirus (HPV) vaccination is expected to prevent cervical cancers caused by the HPV types included in vaccines and possibly by cross-protection from other types. This study sought to determine the hrHPV type distribution in women at a rural Zimbabwe hospital. METHODS We implemented a cross-sectional study at the Karanda Mission Hospital. Using the Visual Inspection with Acetic Acid Cervicography technique, clinicians collected cervical swabs from 400 women presenting for screening for cervical cancer. Samples were initially analyzed by Cepheid GeneXpert; candidate hrHPV genotypes were further characterized using the Anyplex II HPV28 Detection Kit. RESULTS Twenty-one percent of the 400 women were positive for a high-risk genotype when using the GeneXpert analyzer; 17% were positive when using the multiplex analysis. Almost two thirds of the hrHPV women had a single DNA type identified, whereas one third had multiple genotypes, ranging from 2 to 5. hrHPV was observed more frequently in HIV-positive than in HIV-negative women (27% v 15%). Of the 113 isolates obtained, 77% were hrHPV genotypes not included in the bivalent or quadrivalent vaccines, and 47% represented DNA types not covered in the nonavalent vaccine. Forty-seven percent of the women with hrHPV harbored a single genotype that was not covered by the nonavalent vaccine. CONCLUSION A large fraction of hrHPV isolates from women participating in a cervical cancer screening program in northern Zimbabwe are DNA types not covered by the bivalent, quadrivalent, or nonavalent vaccines. These findings suggest the importance of characterizing the hrHPV DNA types isolated from cervical neoplasia in this population and determining whether cross-immunization against these genotypes develops after administration of the vaccines in current use.

Cervical Cancer: 90-70-90 and Palliative Care

Challenges and Opportunities in the Treatment of Invasive Cervical Cancer in Low-Resource Settings: A Survey of the International Gynecologic Cancer Society Fellowship Programs

PURPOSE Cervical cancer remains a leading cause of cancer mortality in low- and middle-income countries (LMICs). The International Gynecologic Cancer Society (IGCS) Global Gynecologic Oncology Fellowship aims to build human capacity to address the burden of cervical cancer in LMICs. This study assesses resource constraints experienced at fellowship sites with regard to management of cervical cancer. METHODS From September to December 2020, one fellow from each of the 12 existing IGCS fellowship programs participated in a survey that assessed capacity for cervical cancer management, including access to care, diagnostics and treatment, cancer surveillance, and palliative care. Descriptive statistics were used for analysis. RESULTS Patients at IGCS sites experienced significant delays to care, especially for chemotherapy and radiation therapy. Less than half of the sites had a gynecology-trained pathologist, and only 58% of sites had access to a magnetic resonance imaging machine, though with many delays in obtaining imaging reads. For treatment, neoadjuvant chemotherapy is not commonly used. Access to radiation therapy is poor, with 58% of sites reporting wait times of 5-8 weeks or more. The radiation machine downtime ranges from 1 to 3 months per year, creating gaps where no patients can access this treatment. Palliative care is practiced by variable members of the health care team although hospice services are rare. CONCLUSION This study demonstrates significant resource constraints experienced by gynecologic oncology providers in various LMICs when managing cervical cancer. This includes delays to diagnosis, poor access to chemoradiation services, and need for palliative care. Despite these limitations, the IGCS Global Gynecologic Oncology Fellowships have built workforce capacity to manage cervical cancer, serving as local champions to address this disease.

Predictors of Survival Outcomes After Primary Treatment of Epithelial Ovarian Cancer in Lagos, Nigeria

PURPOSE This study was designed to investigate the clinicopathologic predictors of progression-free survival (PFS) and overall survival (OS) in patients with epithelial ovarian cancer (EOC) following primary treatment in Lagos, Nigeria. MATERIALS AND METHODS Using data from a retrospective cohort of 126 patients who received treatment for EOC between 2010 and 2018, we identified 83 patients with a complete clinical record for subsequent data analysis. Patients' demographics and updated 2-year follow-up status were abstracted from medical records. Kaplan-Meier survival curves were compared using the log-rank test, and Cox proportional hazard models were used for multivariate analysis to identify independent predictors of survivals following treatment in EOC patients. RESULTS The median PFS and OS were 12 and 24 months, respectively. After adjusting for covariates in the multivariate analysis, younger age ≤ 55 years (hazard ratio [HR] = 0.40; 95% CI, 0.22 to 0.74; P = .01) and International Federation of Gynecology and Obstetrics (FIGO) stage I/II (HR = 0.02; 95% CI, 0.01 to 0.08; P = .01) were independent predictors of improved PFS, whereas being premenopausal (HR = 2.34; 95% CI, 1.16 to 4.75; P = .02) was an independent predictor of reduced OS after 2-year follow-up. CONCLUSION PFS could be predicted by the age and FIGO stage of the disease, whereas menopausal status was predictive of OS in patients with EOC. This knowledge should form the basis for counseling patients with ovarian cancer during their primary treatment and lend support to the importance of aggressive follow-up and monitoring for the older, premenopausal patients and those with an advanced stage of epithelial ovarian cancer. However, robust longitudinal research should be carried out to provide additional reliable insight to this information.

American Society of Clinical Oncology (ASCO) Cervical Cancer Prevention Program: A Hands-On Training Course in Nepal

Cervical cancer is the leading cause of death among women in Nepal. The American Society of Clinical Oncology (ASCO) and The University of Texas MD Anderson Cancer Center collaborated with international and local experts to hold a cervical cancer prevention course in Nepal in November 2019. The course included didactic lectures and a hands-on workshop. The didactic lectures included the epidemiology of cervical cancer globally and locally, cervical cancer screening guidelines, human papillomavirus vaccination, colposcopy and visual inspection with acetic acid (VIA), cervical dysplasia, and cervical cancer treatment. The hands-on workshop consisted of four stations: (1) VIA; (2) colposcopy, cervical biopsy, and endocervical curettage; (3) thermal ablation; and (4) loop electrosurgical excision procedure (LEEP). A train-the-trainer model short course was held by the international faculty to assist six local faculty to become familiar with the instruments, procedures, and models used in the hands-on training stations. Forty-two people (84% gynecologist, 8% radiation oncologist, and 8% other) attended the course. Following the course, the international faculty visited the regional hospitals for additional educational activities. Increased knowledge in cervical cancer screening guidelines and ability in performing VIA, colposcopy and cervical biopsy, thermal ablation, and LEEP were reported by 89%, 84%, 84%, 87%, and 84% of participants, respectively, from the postcourse on-site evaluations. From the 6-month follow-up survey, all respondents reported that they had made practice changes based on what they learned in the course and had implemented or tried to implement the cervical cancer screening guidelines presented at the course. In conclusion, the course evaluations suggested an improvement in participants' ability to perform cervical cancer screening and diagnostic procedures and reported the changes in practices after training.

Randomized Controlled Trial of Impact of Mobile Health Technologies on Human Papillomavirus Vaccination Uptake in Mothers of Vaccine-Eligible Girls in Lagos, Nigeria (mHealth-HPVac)

PURPOSE Expanding high-risk human papillomavirus (HPV) vaccine coverage in resource-constrained settings is critical to bridging the cervical cancer gap and achieving the global action plan for elimination. Mobile health (mHealth) technology via short message services (SMS) has the potential to improve HPV vaccination uptake. The mHealth-HPVac study evaluated the effectiveness of mHealth interventions in increasing HPV vaccine uptake among mothers of unvaccinated girls aged 9-14 years in Lagos, Nigeria. METHODS A randomized controlled trial was conducted at the Lagos University Teaching Hospital between June 2024 and March 2025. We randomly assigned n = 180 eligible mothers to either a text message (intervention) or a usual care (control) arm. The primary analysis was conducted using the intention-to-treat principle. Bivariable and multivariable logistic regression models were performed to compare HPV vaccination uptake between the two arms, adjusting for potential confounders using odds ratios (ORs) and 95% CIs. RESULTS mHealth intervention significantly increased HPV vaccination uptake among mothers of vaccine-eligible girls (adjusted odds ratio [adj OR], 3.05 [95% CI, 1.61 to 5.77]; P = .001). Higher education level was also significantly associated with increased vaccine uptake (adj OR, 3.35 [95% CI, 1.77 to 6.33]; P < .001). There were no significant interaction effects by baseline characteristics on the association between mHealth intervention and HPV vaccine uptake. CONCLUSION The study showed that mHealth interventions significantly improve HPV vaccine uptake. Integrating mHealth strategies into routine immunization programs could be a scalable and cost-effective approach to increasing HPV vaccination coverage. However, future multicenter studies should consider using cluster randomization at the facility level to better optimize mobile interventions for diverse populations, identify the key drivers of successful SMS-based mHealth interventions, and gain deeper insights into the complex barriers to HPV vaccination uptake.

Longitudinal Costs of Image-Guided Intensity-Modulated Radiation Therapy Versus Three-Dimensional Conformal Radiation: Lessons From Phase III PARCER Trial for Shaping Resource-Stratified Guidelines in Low- and Middle-Income Countries

PURPOSE The PARCER trial provided level I evidence for image-guided intensity-modulated radiation therapy (IG-IMRT) in patients with cervical cancer. Further information regarding long-term financial impact is imperative for adoption into the National Cancer Grid of India cervical cancer resource-stratified guidelines. METHODS Patient data from the PARCER trial were analyzed to evaluate the cost implications of transitioning to IG-IMRT. Lacking differences in outcomes between the three-dimensional conformal radiation (3D-CRT) and IG-IMRT, differences in treatment costs, adverse event incidence, and toxicity management costs were examined. The overall financial impact was estimated by adding the treatment costs, toxicity management, and wage loss. This was extrapolated nationally to determine if a transition to IG-IMRT would be feasible for the Indian health care system. RESULTS Of the 300 patients in the PARCER trial, 93 faced grades ≥2 adverse events (3D-CRT = 59, IG-IMRT = 34). Patients in the 3D-CRT and IG-IMRT arms spent an average of 2.39 years and 1.96 years in toxicity, respectively. The average toxicity management and the yearly financial impact per patient were, respectively, 1.50 and 1.44 times higher for 3D-CRT patients compared with IG-IMRT patients. Extrapolation to the national level showed that treatment with 3D-CRT led to a 2.88 times higher cost ratio when compared with treatment with IG-IMRT. CONCLUSION Although the initial costs of IG-IMRT are high, on the basis of longitudinal data, it is financially inefficient to treat with 3D-CRT. Resource-stratified guidelines should include longitudinal health intervention costs rather than solely initial costs for policy decisions to implement advanced radiation technology.

Mobile Technologies and Cervical Cancer Screening in Low- and Middle-Income Countries: A Systematic Review

PURPOSE Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening–related health behaviors. METHODS Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. RESULTS Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). CONCLUSION Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.

Germline Genetic Susceptibility Testing Among Emirati Nationals at Risk for Hereditary Breast and Ovarian Cancer Syndrome

PURPOSE Breast cancer among Emirati patients is characterized by early-onset disease and later stages at presentation. Little is known about the germline genetic variants that may contribute to these observations. The goal of this study is to characterize the rate and implications of germline genetic variants among a cohort of Emirati patients at risk for hereditary breast and ovarian cancer syndrome. MATERIALS AND METHODS A retrospective study was performed to analyze the results of clinical germline genetic testing (March 2020-January 2023) among a cohort of consecutive Emirati patients at risk for hereditary breast and ovarian cancer syndrome: group A: patients with personal history of breast or ovarian cancer (n = 135); group B: unaffected patients with family history of breast or ovarian cancer (n = 37); and group C: patients presenting for cascade testing (n = 20). Management of patients identified to have pathogenic/likely pathogenic (P/LP) variants was analyzed. RESULTS The rate of P/LP germline variants for each group was: group A: 17.3%, group B: 16.6%, group C: 57.9%. BRCA1 gene was the most commonly identified gene harboring P/LP variants, followed by BRCA2 , among this cohort. Four unrelated patients had a recurrent BRCA1 pathogenic variant: c.4065_4068del (p.Asn1355Lysfs*10). Only two patients in this series elected risk-reducing mastectomy and four patients elected risk-reducing bilateral salpingo-oophorectomy. CONCLUSION A higher rate of P/LP variants is seen among Emirati patients at risk for hereditary breast and ovarian cancer syndrome compared with reports of similar patients from Western populations. Efforts to increase utilization and awareness of germline genetic testing are warranted among Emirati patients.

Renewed Commitments to Eliminate Cervical Cancer: What This Means for Low- and Middle-Income Countries

Cervical cancer fight gains momentum as funders meet in Cartagena with the aim of closing gaps in screening, access to vaccines and treatment.

Acceptability of Integrated Community-Based HIV and Cervical Cancer Screening in Mayuge District, Uganda

PURPOSE To assess the acceptability of integrated screening for cervical cancer and HIV in the community setting. METHODS We developed surveys for patients and community health workers (CHWs) who participated in the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge trial that compared self-collected human papillomavirus testing at home versus community health meetings in Mayuge district, Uganda. Quantitative data were summarized using descriptive statistics. Open-ended questions were analyzed using an inductive approach with thematic content analysis. RESULTS We conducted 102 patient surveys and 31 CHW surveys between June and August 2021. Ninety-nine percent of patients and 100% of CHWs indicated that they would find the addition of an HIV test to their self-collected cervical cancer test acceptable. The most frequently stated reasons in favor of adding an HIV test to the ASPIRE Mayuge cervical cancer screening pathways were time-saving, privacy, and support from other women and CHWs. The most frequently stated reasons against integrated screening were related to concerns about confidentiality, most often in reference to women's family members and other women in their village. CONCLUSION Integrated community-based cervical cancer and HIV testing would be highly acceptable to both women and CHWs.

Artificial Intelligence–Based Radiotherapy Contouring and Planning to Improve Global Access to Cancer Care

PURPOSE Increased automation has been identified as one approach to improving global cancer care. The Radiation Planning Assistant (RPA) is a web-based tool offering automated radiotherapy (RT) contouring and planning to low-resource clinics. In this study, the RPA workflow and clinical acceptability were assessed by physicians around the world. METHODS The RPA output for 75 cases was reviewed by at least three physicians; 31 radiation oncologists at 16 institutions in six countries on five continents reviewed RPA contours and plans for clinical acceptability using a 5-point Likert scale. RESULTS For cervical cancer, RPA plans using bony landmarks were scored as usable as-is in 81% (with minor edits 93%); using soft tissue contours, plans were scored as usable as-is in 79% (with minor edits 96%). For postmastectomy breast cancer, RPA plans were scored as usable as-is in 44% (with minor edits 91%). For whole-brain treatment, RPA plans were scored as usable as-is in 67% (with minor edits 99%). For head/neck cancer, the normal tissue autocontours were acceptable as-is in 89% (with minor edits 97%). The clinical target volumes (CTVs) were acceptable as-is in 40% (with minor edits 93%). The volumetric-modulated arc therapy (VMAT) plans were acceptable as-is in 87% (with minor edits 96%). For cervical cancer, the normal tissue autocontours were acceptable as-is in 92% (with minor edits 99%). The CTVs for cervical cancer were scored as acceptable as-is in 83% (with minor edits 92%). The VMAT plans for cervical cancer were acceptable as-is in 99% (with minor edits 100%). CONCLUSION The RPA, a web-based tool designed to improve access to high-quality RT in low-resource settings, has high rates of clinical acceptability by practicing clinicians around the world. It has significant potential for successful implementation in low-resource clinics.

Patient Decision Aid for Chemotherapy or Exclusion in Cisplatin-Intolerant Patients With Locally Advanced Cervical Cancer: Development, Alpha Testing, and Peer Validation

PURPOSEIn locally advanced cervical cancer (LACC), adding cisplatin to radiotherapy (RT) improves survival but increases toxicity. Among patients with cisplatin contraindications, RT compliance may be compromised by toxicity because of cisplatin or a substitute. In shared decision making, a patient decision aid (PtDA) may decrease decisional conflict and attitudinal barriers, thereby improving treatment compliance.METHODSFollowing International Patient Decision Aid Standards (IPDAS) guidelines, a steering committee of two radiation oncologists, a gynecologic oncologist, an oncology nurse, a clinical psychologist, a cancer survivor, and a caregiver developed the chemotherapy or exclusion in cisplatin-intolerant patients with LACC (CECIL) prototype, a PtDA for cisplatin-intolerant patients with LACC deciding about adding chemotherapy to RT. The prototype was alpha-tested using the e-Delphi method. The patient decision aid research group Ottawa Acceptability Questionnaire was used to evaluate comprehensibility, length, amount of information, neutrality, and overall suitability for decision making. The prototype was then independently evaluated by local internal, local external, and international reviewers using the IPDAS checklist version 4, which encompasses information, probabilities, values, guidance, development, evidence, disclosure, plain language, and evaluation.RESULTSAlpha testing showed high practitioner acceptability (all items with mean and median scores ≥4; overall mean score 4.70 of 5.00) and good patient acceptability (all items rated good to excellent). Content validation showed that the PtDA satisfied all IPDAS six qualifying and six certification criteria, with high overall mean score (3.63 of 4.00) for all 17 applicable quality criteria.CONCLUSIONThe CECIL prototype shows good practitioner and patient acceptability, and content validity on peer review. Clinical testing to determine its effectiveness in reducing decisional conflict is ongoing.

PARP Inhibitor in Platinum-Resistant Ovarian Cancer: Single-Center Real-World Experience

PURPOSE Poly (ADP-ribose) polymerase inhibitors (PARPi) have proven efficacy in treatment of BReast CAncer ( BRCA) gene mutation-positive platinum-sensitive ovarian cancers. There is paucity of data for their role in platinum-resistant ovarian cancer (PROC). We report here retrospective analysis of outcome of PARPi treatment in a group of patients including those of PROC. PATIENTS AND METHODS We analyzed all consecutive patients who received PARPi. The efficacy of PARPi monotherapy was assessed in patients with relapsed high-grade serous ovarian carcinoma with g BRCAm. The drug was procured through compassionate program. Drugs (olaparib and talazoparib) were provided in capsule form. RESULTS Between July 1, 2015, and June 30, 2019, 28 patients with ovarian cancer received PARPi. At the time of data censoring (September 30, 2019), four (14.3%) patients are still on treatment. Median age was 54.5 years (range, 39-75 years). Median number of previous lines of chemotherapy received was three (range, 1-6). Eleven platinum-sensitive patients received the drug as maintenance (five in complete response and six in partial response after chemotherapy), whereas 17 (60.7%) had platinum-resistant progressive disease while starting the drug. In PROC, objective response rate (complete response plus partial response) was 47%, median progression-free survival was 8.2 months (5.3-11.3), and overall survival was 14.9 months (11.2-18.5). No new side effects were observed. CONCLUSION This is the first study from India evaluating PARPi in platinum-resistant ovarian cancer. This study suggests that PARPi is a viable treatment option in patients with PROC with gBRCAm. This should be further evaluated in randomized clinical trial.

Outcomes for Step-Wise Implementation of a Human Papillomavirus Testing–Based Cervical Screen-and-Treat Program in El Salvador

PURPOSE The Cervical Cancer Prevention in El Salvador (CAPE) project is a public-sector intervention introducing lower-cost human papillomavirus (HPV) testing in all four departments of the Paracentral region that screened a total of 28,015 women. After demonstrating success of an HPV screen-and-treat (S&T) algorithm over colposcopy management in the first two phases, the third phase scaled up the S&T strategy. We present results from phase III and evaluate S&T components across the entire project. METHODS During phase III, 17,965 women age 30-59 years underwent HPV testing. HPV-positive women were asked to return and, if eligible, received gas-based cryotherapy. We compare loss to follow-up and time intervals between S&T steps across the three phases. RESULTS There were no differences in HPV positivity across phases (phase I, 11.9%; phase II, 11.4%; phase III, 12.3%; P = .173). Although most HPV-positive women completed indicated follow-up procedures within 6 months in phases I (93.3%, 111 of 119) and II (92.3%, 429 of 465), this proportion declined to 74.9% (1,659 of 2,214; P < .001) in phase III. Mean days between testing and delivery of results to patients increased over program phases (phase I, 23.2 days; phase II, 46.7 days; phase III, 99.8 days; P < .001). CONCLUSION A public-sector implementation of an HPV-based S&T algorithm was successfully scaled up in El Salvador, albeit with losses in efficiency. After CAPE, the Ministry of Health changed its screening guidelines and procured additional tests to expand the program.

Cervical Cancer Treatment in HIV-Positive Patients: A Survey of Treatment Practices in India

PURPOSE Chemoradiation remains a challenge in women living with HIV (WLWH) and cervical cancer primarily because of concerns regarding immune status. With limited literature available to help guide the management of these patients, clinical practices among oncologists are variable across India. Hence, we conducted a survey among radiation oncologists in India to assess the patterns of current practices of treating cervical cancer with chemoradiation in WLWH. MATERIALS AND METHODS A questionnaire consisting of 12 questions related to the treatment of cervical cancer in WLWH was distributed to radiation oncologists at two national conferences in India. RESULTS The questionnaire was distributed to 105 radiation oncologists, and 90 (85.7%) responses were received. 95.5% of respondents reported that patients with advanced cervical cancer constituted the majority of their practice. Chemoradiation was reported as the most common modality of planned treatment. Ninety-four percentage of respondents reported that they referred patients to an antiretroviral therapy clinic before starting definitive treatment. The majority of respondents (68%) do not plan for concurrent chemotherapy if CD4 counts were < 200 cells/mm3. As many as 50% of respondents reported that they would only start antiretroviral therapy when CD4 counts drop. Poor social support (37.6%), concurrent infections during treatment (28.2%), acute toxicities (21.2%), and poor nutrition (13%) were cited as the most common reasons for treatment interruption in cervical cancer patients with HIV. CONCLUSION This survey highlights the prevalent inconsistencies in treatment protocols employed by radiation oncologists in India for the management of locally advanced cervical cancer in WLWH. It also reflects the need for social and nutritional support to help improve compliance and thereby improve outcomes in these patients.

Long-Term Toxicity and Efficacy of Intensity-Modulated Radiation Therapy in Cervical Cancers: Experience of a Cancer Hospital in Pakistan

PURPOSE To report the chronic toxicity and disease outcomes attributable to intensity-modulated radiation therapy (IMRT) in patients with cervical cancer. METHODS AND MATERIALS Between January 2014 and December 2018, a retrospective review of medical records of patients with cervical cancer who received radiation therapy with IMRT was performed. Disease and treatment-related details were documented. Follow-up notes were reviewed, and severity of late toxicities was recorded. Overall survival (OS) and disease-free survival (DFS) at 3 years were estimated. RESULTS A total of 222 patients’ records were reviewed. Mean age was 50.7 years. Median follow-up duration was 33 months (range, 2-70 months). The most common toxicity was vaginal stricture (grade 2, n = 59, 26.6%; grade 3, n = 4, 1.80%), followed by proctitis (grade 2, n = 24; 10.8%; grade 3, n = 7; 3.20%). Seven patients (grade 2, n = 5, 2.3%; grade 3, n = 2; 0.90%) developed cystitis, and only 5 (grade 2; 2.3%) were found to have colitis. None of the patients had grade 4 or grade 5 toxicities. There was a significant difference in late complications in patients with nodal disease or those who underwent prior surgery ( P < .05). Three-year OS and DFS rates were 79.7% and 81.9%, respectively. Patients with tumor size > 5 cm and those with pelvic lymph node metastasis had poor survival rates ( P < .05). CONCLUSION IMRT is an effective and well-tolerated technique that should be considered in patients with lymph node disease and in postoperative patients. There is an inverse relationship between tumor size and nodal involvement with respect to OS and DFS.

Chemoradiation in Stage IIIB Cancer of the Uterine Cervix: A Review of the Zimbabwean Experience

PURPOSE Cervical cancer remains the leading cause of cancer morbidity and mortality among Zimbabwean women. Many patients present with stage IIIB disease. Although definitive concurrent chemoradiation (CCRT) is the standard of care, there is a paucity of data on the effect(s) of this intervention in resource-constrained and high HIV-prevalence settings. We investigated the differences in CCRT initiation practices, tolerability, and outcomes in this group. PATIENTS AND METHODS We performed a retrospective analysis of data from hospital records for patients with stage IIIB disease who were treated over a 2-year period at Parirenyatwa Group of Hospitals. Outcome measures were documented treatment-related adverse events and early clinical tumor response. RESULTS One hundred twenty-eight (37%) of 346 patients received CCRT, and 65 (51%) of 128 patients were infected with HIV. CCRT was prescribed mostly in patients with less extensive disease—not involving lower third vaginal walls, minimal pelvic sidewall involvement ( P = .002), and higher CD4+ count ( P = .02). Eighteen percent of recorded adverse events were high grade (≥ 3). One patient did not complete treatment, and 68.5% achieved complete clinical tumor response at 3 months post-CCRT. A higher proportion of complete clinical tumor response was noted in those patients who were young, HIV uninfected, had less extensive disease, CD4+ of 500 cells/mm3 or greater, received four or more cycles of chemotherapy, received brachytherapy, and had no treatment breaks. CONCLUSION The study revealed that the use of CCRT to treat stage IIIB cervical cancer is low in Zimbabwe. Although several factors contribute, low CCRT uptake is mostly attributed to financial barriers. Well-selected patients tolerate the treatment and have good early clinical tumor response as expected. The role of CCRT for this patient group (and methods to make it available in resource-limited settings) must be further evaluated.

Promise of Smartphone-Enabled Teleconsultation for Global Cancer Prevention

Years of Potential Life Lost Because of Breast and Cervical Cancers in Guatemala

PURPOSE Worldwide cervical and breast cancers are among the most commonly diagnosed cancers and are leading cause of cancer deaths among females in low- and middle-income countries. In Guatemala, breast and cervical cancers are the main cause of cancer-related deaths among women. Therefore, the aim of this study was to determine the years of potential life lost (YPLL) as an indicator of premature deaths as a result of breast and cervical cancers. METHODS Data on the number of deaths as a result of breast and cervical cancers (International Classification of Diseases [10th revision] codes C50 and C53) between 2012 and 2016 and age composition by quinquennials were retrieved from the Health Information System of the Guatemalan Health Ministry. On the basis of each individual’s age at death, YPLL was estimated for females between 20 and 70 years of age. RESULTS A total of 1,476 deaths related to breast and cervical cancers was reported over the study period. The trend in breast cancer mortality rate and YPLL did not change from 2012 to 2016. The cervical cancer mortality rate has decreased to 10 deaths per 1 million habitants ( P = .046). There has been a reduction in YPLL because of cervical cancer, from 50.18 YPLL in 2012 to 29.19 YPLL by 2016, mainly in women between 30 and 34 years of age, in whom YPLL decreased from 600 to 112.50 ( P = .046). CONCLUSION Cervical cancer screening has significantly reduced the mortality rate of this malignancy, and screening of breast cancer must include creating awareness of the disease and providing access to women at risk.

Impact of COVID-19 on Outcomes for Patients With Cervical Cancer in India

PURPOSE The COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India. METHODS We used a Markov-model–based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease. RESULTS We estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years. CONCLUSION Delays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.

Accuracy of Smartphone Images of the Cervix After Acetic Acid Application for Diagnosing Cervical Intraepithelial Neoplasia Grade 2 or Greater in Women With Positive Cervical Screening: A Systematic Review and Meta-Analysis

PURPOSE Smartphones are used in cervical screening for visual inspection after acetic acid or Lugol's iodine (VIA/VILI) application to capture and share images to improve the sensitivity and interobserver variability of VIA/VILI. We undertook a systematic review and meta-analysis assessing the diagnostic accuracy of smartphone images of the cervix at the time of VIA/VILI (termed S-VIA) in the detection of precancerous lesions in women undergoing cervical screening. METHODS This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 1, 2010, to June 30, 2020, were assessed. MEDLINE/PubMed, Embase, CINAHL, Cochrane, and LILACS were searched. Cohort and cross-sectional studies were considered. S-VIA was compared with the reference standard of histopathology. We excluded studies where additional technology was added to the smartphone including artificial intelligence, enhanced visual assessment, and other algorithms to automatically diagnose precancerous lesions. The primary outcome was the accuracy of S-VIA for the diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN 2+). Data were extracted, and we plotted the sensitivity, specificity, negative predictive value, and positive predictive value of S-VIA using forest plots. This study was prospectively registered with The International Prospective Register of Systematic Reviews:CRD42020204024. RESULTS Six thousand three studies were screened, 71 full texts assessed, and eight studies met criteria for inclusion, with six included in the final meta-analysis. The sensitivity of S-VIA for the diagnosis of CIN 2+ was 74.56% (95% CI, 70.16 to 78.95; I2 61.30%), specificity was 61.75% (95% CI, 56.35 to 67.15; I2 95.00%), negative predictive value was 93.71% (95% CI, 92.81 to 94.61; I2 0%), and positive predictive value was 26.97% (95% CI, 24.13 to 29.81; I2 61.3%). CONCLUSION Our results suggest that S-VIA has accuracy in the detection of CIN 2+ and may provide additional support to health care providers delivering care in low-resource settings.

Point-Based Brachytherapy in Cervical Cancer With Limited Residual Disease: A Low- and Middle-Income Country Experience in the Era of Magnetic Resonance–Guided Adaptive Brachytherapy

PURPOSE To evaluate the clinical outcomes in patients with cervical cancer with limited residual disease at brachytherapy (BT) treated with point-based dose prescription. METHODS Patients with locally advanced squamous cell carcinoma of the cervix treated with computed tomography (CT)-based intracavitary BT were considered for analysis. Patients with good response to external beam radiotherapy and limited residual disease suitable for intracavitary BT alone were included. Postapplication CT scans were performed before each fraction and individual plans were made for each session. The dose per fraction was 9Gy high dose rate, prescribed to point-A. Two sessions were planned, 1 week apart. The organs at risk were contoured, and cumulative dose-volume histograms were computed. Local control, pelvic control, disease-free survival, and overall survival were evaluated and late toxicities were documented. RESULTS Four hundred ninety patients were included. Overall, 79.8% had International Federation of Gynecology and Obstetrics (FIGO) stage IB2 to IIB disease and 20.2% had stage III to IVA disease. Median dose at point A (EQD210Gy) was 74.4 Gy (interquartile range [IQR] 72.3-74.5 Gy) and median D2cc (EQD23Gy) for bladder, rectum, and sigmoid were 82.5 Gy (IQR, 65.5-90.8 Gy), 66.5 Gy (IQR, 60.7-75.7 Gy), and 54.1 Gy (IQR, 50.5-77.3 Gy), respectively. At a median follow-up of 62 (IQR, 33-87) months, the 5-year local and pelvic control rates were 90.1% and 88.3%, respectively. The 5-year disease-free survival was 80% and overall survival was 88%. Rates of grade 3-4 bladder and rectosigmoid toxicities were 6.93% and 4.08%, respectively. CONCLUSION In patients with limited residual disease at BT, point-based dose prescription with CT planning results in good local control and acceptable toxicity. In a resource-constrained setting, patients may be triaged to receive point-based BT or magnetic resonance imaging–guided adaptive BT depending on the extent of residual disease.

Impact of Mobile Technologies on Cervical Cancer Screening Practices in Lagos, Nigeria (mHealth-Cervix): A Randomized Controlled Trial

PURPOSE We assessed the impact of mHealth on Pap test screening uptake and also determined the factors that affect screening uptake among women in Lagos, Nigeria. MATERIALS AND METHODS A randomized controlled trial was carried out among women in two tertiary health institutions in Lagos, Nigeria, between July 2020 and March 2021. Participants were randomly assigned to either a text message (mHealth) intervention or usual care arm. The main study outcome was the uptake of Pap smear testing within 6 months of enrollment in the study. We tested the associations between two groups of continuous variables using the unpooled independent-sample t-test (normal distribution) and that of two groups of categorical variables with the chi-square (χ2) test. Using a multinomial logistic regression model, we adjusted for relevant sociodemographic and clinical predictors of uptake of Pap smear screening. Statistical significance was defined as P < .05. RESULTS There was a significantly higher rate of uptake of Pap smear screening among women in the mHealth arm compared with those in the usual care arm (51.0% v 35.7%, P = .031). Following adjustment in the final multivariate model, level of income (odds ratio [OR] = 5.13, 95% CI, 1.55 to 16.95), awareness of Pap smear (OR = 16.26; 95% CI, 2.49 to 76.64), General Outpatient clinic attendance, and introduction of mHealth intervention during follow-up (OR = 4.36; 95% CI, 1.44 to 13.22) were the independent predictors of Pap smear uptake. CONCLUSION The use of mHealth technologies intervention via short-text message services is a feasible solution for cervical cancer prevention in low- and middle-income countries, and thus, the widespread use of mHealth services by health care providers and policymakers could contribute to the implementation of cervical cancer prevention services in Nigeria and in the settings of other low- and middle-income countries.

Yes! To Scaling Up Cervical Cancer Screening With Self-Collection: But the Cost of HPV Screening Must Be Reduced

Underreported Breast and Cervical Cancer Deaths Among Brought-In-Dead Cases in Zambia

Burden of Risk Factors for Cervical Cancer Among Women Living in East Africa: An Analysis of the Latest Demographic Health Surveys Conducted Between 2014 and 2017

PURPOSE In East Africa, cervical cancer is a leading cause of morbidity and mortality among women diagnosed with cancer. In this study, we describe the burden of risk factors for cervical cancer among women of reproductive age in five East African countries. METHODS For each country, using STATA13 software and sampling weights, we analyzed the latest Demographic and Health Survey data sets conducted between 2014 and 2017 in Burundi, Kenya, Rwanda, Tanzania, and Uganda. We included women age 15-49 years and considered six risk factors (tobacco use, body mass index, age at first sexual intercourse, age at first birth, number of children, and hormonal contraceptive use). RESULTS Of the 93,616 women from the five countries, each country had more than half of the women younger than 30 years and lived in rural areas. Pooled proportion of women with at least one risk factor was 89% (95% CI, 87 to 91). Living in a rural area in Burundi (adjusted incidence rate ration 0.94; 95% CI, 0.9 to 0.99; P = .019) and Rwanda (adjusted incidence rate Ration 0.92; 95% CI, 0.88 to 0.96; P < .001) was associated with a lower number of risk factors compared with living in an urban area. In all the countries, women with complete secondary education were associated with a lower number of risk factors compared with those with no education. CONCLUSION This study reveals a high burden of risk factors for cervical cancer in East Africa, with a high proportion of women exposed to at least one risk factor. There is a need for interventions to reduce the exposure of women to these risk factors.

Safety and Acceptability of Three Ablation Treatments for High-Grade Cervical Precancer: Early Data From a Randomized Noninferiority Clinical Trial

PURPOSE This ongoing trial is comparing the efficacy and safety of three ablation treatments for cervical intraepithelial neoplasia grade 2 or higher. Here, we present early data regarding pain, side effects, and acceptability of CO2 gas-based cryotherapy (CO2), nongas cryotherapy, and thermal ablation (TA). Efficacy results are expected to become available in late 2023. MATERIALS AND METHODS This noninferiority randomized trial is taking place in El Salvador, China, and Colombia. Patients are 1,152 eligible women with biopsy-confirmed cervical intraepithelial neoplasia grade 2 or higher who will receive one of three ablation treatments. Pain is measured before, during, and after treatment with a visual analog scale (1-10). Side effects and acceptability are assessed at 6 weeks. RESULTS To date, 1,024 of 1,152 (89%) women were randomly assigned to treatment. The median pain level was higher during TA (4, IQR = 4) than CO2 (2, IQR = 4) or nongas cryotherapy (2, IQR = 4) ( P < .01, range: 0-10). The most common post-treatment symptom was watery discharge, reported by 97.9% of women, and it lasted longer in the CO2 group than the other two treatments (in days, median [IQR]: CO2 = 20[20], nongas cryotherapy = 15[10], TA = 18[15], P < .01). Bleeding was reported more frequently in women treated with TA (27.6%) than CO2 (17.5) or nongas cryotherapy (18.7%) ( P < .01). The majority of patients reported being very satisfied with the treatment they received at 6 weeks (91%) and again at 12 months post-treatment (97%). CONCLUSION Despite differences in pain and side effects across ablation treatments, all were safe and highly acceptable to patients. In addition to efficacy, considerations such as cost and portability may be more significant in choosing a treatment method.

Integrating Breast Cancer Early Detection Into a Resource-Constrained Primary Health Care System: Health Care Workers' Experiences in Rwanda

PURPOSE There is limited evidence to guide incorporation of breast cancer early detection into resource-constrained health systems where mammography screening is not yet available. To inform such strategies, we sought to understand health care workers' perspectives on a breast cancer early detection initiative integrated into community, primary, and secondary levels of care in Rwanda. METHODS We conducted a qualitative study using semistructured interviews with 33 community health workers, clinicians, and administrators at health facilities participating in the Women's Cancer Early Detection Program (WCEDP), through which women received clinical breast examination if they were receiving cervical cancer screening, or had breast concerns. Through thematic analysis, we identified dynamics and patterns associated with successes and challenges of the program's breast health services. RESULTS Successes and challenges identified by participants corresponded with the community- and primary care–based steps of cancer early diagnosis identified by the WHO. Regarding step 1 (community awareness/access), participants noted increases in awareness and care-seeking. Challenges included difficulty overcoming stigma and engaging older women. Regarding step 2 (clinical evaluation), all participants described increased breast health knowledge, skills, and confidence. Integrating the WCEDP with other services was challenging because of inadequate staffing; offering WCEDP services on a designated day/week had advantages and disadvantages. Although participants appreciated WCEDP referral mechanisms, they desired more communication from referral facilities. Patients' poverty was the most consistently identified impediment to referral completion. CONCLUSION Rwandan health care workers identified real-world successes and challenges of implementing principles of early cancer diagnosis for breast cancer early detection. Future interventions should focus on engagement of older women, community awareness, patient socioeconomic support, and optimizing integration into primary care.

Role of Local Evidence in Transferring Evidence-Based Interventions to Low- and Middle-Income Country Settings: Application to Global Cancer Prevention and Control

PURPOSE Although the global burden of cancer falls increasingly on low- and middle-income countries (LMICs), much of the evidence for cancer prevention and control comes from high-income countries and may not be directly applicable to LMIC settings. In this paper, we focus on the following question: When the majority of the evidence supporting an evidence-based intervention or implementation strategy comes from high-income countries, what local, contextual evidence is needed when transferring and adapting an intervention or strategy to a specific LMIC setting? METHODS We draw on an existing framework (the Population, Intervention, Environment, Transfer-T process model) for assessing transferability of interventions between distinct settings and apply the model to two case studies as learning examples involving implementation of tobacco use treatment guidelines and self sampling for human papillomavirus DNA in cervical cancer screening. RESULTS These two case studies illustrate how researchers, policymakers, practitioners, and consumers may approach the need for local evidence from different perspectives and with different priorities. As uses and expectations around local evidence may be different for different groups, aligning these priorities through multistakeholder engagement in which all parties participate in defining the questions and cocreating the solutions is critical, along with promoting standardized reporting of contextual factors. CONCLUSION Local, contextual evidence can be important for both researchers and practitioners, and its absence may hinder translation of research and implementation efforts across different settings. However, it is essential for researchers, practitioners, and other stakeholders to be able to clearly articulate the type of data needed and why it is important. In particular, where resources are limited, evidence generation should be prioritized to address real needs and gaps in knowledge.

Impact of COVID-19 in Cervical and Breast Cancer Screening and Systemic Treatment in São Paulo, Brazil: An Interrupted Time Series Analysis

PURPOSE COVID-19 caused a disruption in cancer management around the world, resulting in an estimated excess burden secondary to screening disruption and excess lag time for treatment initiation. METHODS We gathered information from primary reimbursement data sets of the public health system of São Paulo, Brazil, from April 2020 to November 2021, and compared these data with those of the pre–COVID-19 period. We used an interrupted time series model to estimate the effect of the COVID-19 pandemic on the rate of key procedures of breast and cervical cancer health care chain. RESULTS We estimated that 1,149,727, 2,693, and 713,616 pap smears, conizations, and mammograms, respectively, were missed or delayed during the COVID-19 pandemic, compared with those in the years immediately before the COVID-19 stay-at-home restrictions. Specifically, we observed an acute decrease of procedures after the COVID-19 stay-at-home restrictions, with a trend to recovery in the long term. Regarding the systemic treatment analysis, we observed a 25% reduction in the rate of initiation of adjuvant systemic treatment for early breast cancer (stage I/II). However, we did not find a clear effect on the other settings of systemic treatment for breast cancer. We estimated an excess of 156 patients starting palliative care for cervical cancer after the COVID-19 stay-at-home restrictions. CONCLUSION The COVID-19 pandemic significantly reduced the performance rate of pap smears, conizations, and mammograms. The initiation of adjuvant treatment for early-stage breast cancer was most susceptible to COVID-19's health system disruption. Furthermore, the downward trend of treatment of advanced cervical cancer was interrupted. Therefore, public health policies are urgently needed to decrease the incidence of advanced cervical and breast cancers caused by delayed diagnosis and treatment initiation. The COVID-19 control policies resulted in reduction of cancer patients' delivery of care. This study evaluated the pandemic's influence in key procedures of breast and cervical cancer chain of care in São Paulo, Brazil. We observed a substantial reduction in the number of mammograms, pap smears, and conizations performed since the onset of the COVID-19 pandemic. In addition, stage I and II breast cancer adjuvant treatment presented a reduced realization rate, whereas palliative treatment delivered for advanced cervical cancer increased. Our results support the need for public health policies focused on mitigating the long-term effects of COVID-19 in cancer-related mortality.

Outcomes of Cervical Cancer in HIV-Positive Women Treated With Radiotherapy at a Tertiary Care Center in India

PURPOSE There are limited data on management of cervical cancer in women living with HIV in the modern antiretroviral therapy era. The study aimed to evaluate outcomes and toxicities of these patients treated with radiotherapy. MATERIALS AND METHODS A retrospective analysis of HIV-positive cervical cancer patients treated with radiotherapy between 2011 and 2018 was conducted at a tertiary care center in India. RESULTS Eighty-two HIV-positive cervical cancer patients treated with radiotherapy were identified. Their median age was 45 years. Seventy-four (90%) patients received radiotherapy with curative-intent and eight patients received palliative radiotherapy. Median CD4 count at the start of treatment was 342 cells/mm3 (interquartile range: 241-531). Among patients planned for definitive radiotherapy, concurrent cisplatin was planned in 52 (70%) patients with a median of four chemotherapy cycles, and 81% (n = 60) patients received brachytherapy. Among patients who received brachytherapy, the median prescription dose was 80 Gy. Seventy-seven patients completed their prescribed treatment. At a median follow-up of 37 months, 3-year disease-free survival of patients planned with curative-intent was 54%. On multivariate analysis, treatment completion was associated with favorable disease-free survival. Grade III/IV acute gastrointestinal toxicity was seen in five (6.8%) patients, whereas 30% patients had grade III/IV acute hematologic toxicity. All these patients completed their planned radiotherapy with good supportive care. CONCLUSION Standard treatment of chemoradiation should be planned in women living with HIV with well-managed HIV presenting with locally advanced cervical cancer. Our study highlights the need for optimal management of these patients by a multidisciplinary team with intensive supportive care to ensure completion of planned treatment to achieve better outcomes.

Management and Care of Patients With Invasive Cervical Cancer: ASCO Resource-Stratified Guideline Rapid Recommendation Update

ASCO Rapid Recommendations Updates highlight revisions to select ASCO guideline recommendations as a response to the emergence of new and practice-changing data. The rapid updates are supported by an evidence review and follow the guideline development processes outlined in the ASCO Guideline Methodology Manual. The goal of these articles is to disseminate updated recommendations, in a timely manner, to better inform health practitioners and the public on the best available cancer care options.

Cost Effectiveness of Bevacizumab Plus Chemotherapy for the Treatment of Advanced and Metastatic Cervical Cancer in India—A Model-Based Economic Analysis

PURPOSE Patients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India. METHODS Using a disaggregated societal perspective and lifetime horizon, a Markov model was developed for estimating the costs and health outcomes in a hypothetical cohort of 1,000 patients with advanced and metastatic cervical cancer treated with either standard chemotherapy alone or in combination with bevacizumab. Effectiveness data for each of the treatment regimen were assessed using estimates from Gynecologic Oncology Group 240 trial. Data on disease-specific mortality in metastatic cervical cancer, health system cost, and out-of-pocket expenditure were derived from Indian literature. Multivariable probabilistic sensitivity analysis was undertaken to account for parameter uncertainty. RESULTS Over the lifetime of one patient with advanced and metastatic cervical cancer, bevacizumab along with standard chemotherapy results in a gain of 0.275 (0.052-0.469) life-years (LY) and 0.129 (0.032-0.218) quality-adjusted life-years (QALY), at an additional cost of $3,816 US dollars (USD; 2,513-5,571) compared with standard chemotherapy alone. This resulted in an incremental cost of $19,080 USD (7,230-52,434) per LY gained and $34,744 USD (15,782-94,914) per QALY gained with the use of bevacizumab plus standard chemotherapy. CONCLUSION Addition of bevacizumab to the standard chemotherapy is not cost effective for the treatment of advanced and metastatic cervical cancer in India at a threshold of 1-time per-capita gross domestic product.

Hands-On Training Courses for Cervical Cancer Screening, Diagnosis, and Treatment Procedures in Low- and Middle-Income Countries

In 2018, there were approximately 570,000 new cases of cervical cancer worldwide. More than 85% of cases occurred in low- and middle-income countries (LMICs), primarily because of poor access to screening and a limited number of medical providers trained to diagnose and treat cervical precancerous lesions. Our objective was to provide locally arranged, hands-on training courses for medical providers in LMICs to learn to perform cervical cancer screening, diagnosis, and treatment procedures. The courses included didactic lectures and hands-on training stations using low-cost simulation models developed by bioengineers and students at Rice University in Houston, TX, United States, and the Malawi Polytechnic in Blantyre, Malawi. The hands-on training stations included visual inspection with acetic acid (VIA), colposcopy, cervical biopsy, endocervical curettage, loop electrosurgical excision procedure (LEEP), and thermal ablation. Provider pre- and postcourse confidence levels in performing the procedures were evaluated. From February 2017 to January 2020, we arranged 15 hands-on training courses in seven cities across six countries (El Salvador, Mozambique, Trinidad and Tobago, Lesotho, Malawi, and Nepal). Overall, there were 506 participants. The average number of participants per course was 38 (range 19-92). The participants included doctors, nurses, and midwives. The course duration varied from 1 to 3 days. Increased confidence in performing VIA, colposcopy and cervical biopsy, ablation, and LEEP was reported by 69%, 71%, 61%, and 76% of participants, respectively. Our findings suggest that locally arranged, hands-on cervical cancer prevention training courses in LMICs can improve provider confidence in performing cervical cancer screening, diagnosis, and treatment procedures. These courses are part of a larger strategy to build local capacity for delivering and improving cervical cancer prevention services in LMICs.