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Self-collection of vaginal specimens for human papillomavirus testing in cervical cancer prevention (MARCH): a community-based randomised controlled trial

By Ziad Khatib Moderator Emeritus | 14 Nov, 2011

Hello,
I am sharing a recent paper by Lazcano-Ponce et.al. from Mexico. An elegant randomized trial, that compared HPV DNA testing, self-collected vaginal samples, vs. cervical cytology.
HPV DNA testing was much more sensitive than cytology. However it has lower positive predictive value.
It is a very relevant topic for limited-resource settings, where there is no cytology infrastructure.

I would be curious to know about the NCD community feedback on the questions of going for HPV DNA testing vs. cytology.
What can be the consequences for the health care system to (1) invite more women for screening but they might not come back for follow-up or (2) wait until they present with invasive cancer?



Thank you,
Ziad

Attached resource:
  • Self-collection vaginal samples in limited-resource settings (download, 186.5┬áKB)

    Summary: Hello,
    I am sharing a recent paper by Lazcano-Ponce et.al. from Mexico. An elegant randomized trial, that compared HPV DNA testing, self-collected vaginal samples, vs. cervical cytology.
    HPV DNA testing was much more sensitive than cytology. However it has lower positive predictive value.
    It is a very relevant topic for limited-resource settings, where there is no cytology infrastructure.

    I would be curious to know about the NCD community feedback on the questions of going for HPV DNA testing vs. cytology.
    What can be the consequences for the health care system to (1) invite more women for screening but they might not come back for follow-up or (2) wait until they present with invasive cancer?



    Thank you,
    Ziad

    Source: The Lancet

    Keywords: cancer, Cervical Cancer screening, Innovations for Resource-Limited Settings, Mexico, Publications & Research, Risk Factors & Prevention

Replies

 

Maggie Sullivan Replied at 1:31 PM, 22 Nov 2011

Hi Ziad,
Thank you for sharing this study. PIH is currently using self-collected HPV testing in Haiti. My work with them in Guatemala does not yet include HPV testing, but we are moving away from cytology and relying solely on visual inspection with ascetic acid (VIA) and cryotherapy. Having access to HPV testing is a critical tool that needs inclusion.

I definitely think that in certain environments, cytology is much less preferable. In Guatemala, for example, there is no LBC (liquid-based cytology) but only conventional cytology (slides that require fixation). This difference alone makes cytology less sensitive as a screening tool. Compounding this problem, the quality of laboratory review of cytologic specimens is highly variable in many low-resourced countries. Not to mention, the rate of return on pap results is low.

I don't think the question lies so much with whether or not cytology should be ushered out the door in some countries, as what exactly should it be replaced with? VIA/cryo alone, HPV rapid testing alone or a combination of the two? And should we accept the lower sensitivity of self-collected HPV tests, or encourage clinician-collected HPV samples? I'd love to hear others' input!
-Maggie Sullivan

Ziad Khatib Moderator Emeritus Replied at 11:02 AM, 25 Nov 2011

Dear Maggie,
Thank you, totally agree with you. I would be interested in knowing the clinical implications of these different screening methods. Mainly when to ask patients to come back for a follow-up test? And can this risk loosing patients on long-term?

Others, any input?

Ziad

Ziad Khatib Moderator Emeritus Replied at 11:59 PM, 3 Dec 2011

A follow-up article regarding pap screening:
Making Sense of the New Cervical-Cancer Screening Guidelines
By Dr. Sarah Feldman.
http://www.nejm.org/doi/full/10.1056/NEJMp1112532

Erin Meier Replied at 12:44 AM, 27 Dec 2011

Ziad - here in Papua New Guinea, we struggle with cervical cancer screening for many reasons. We have no ability, where I am at, to do HPV DNA testing, so that isn't an option. We do have pap smears, which we send to Australia, but the results take 2-3 months to get back. Some women come for followup at that time and many do not. We have so much advanced cervical cancer that we are often skipping these preliminary steps in many women and going right to surgery or palliative care, depending how their findings when they present.

We do VIA when we find an abnormal exam on bimanual/speculum exam and then can do cryotherapy if needed. We do colpos for abnormal paps when they come back, if they return for f/u. I still live in a bush place where although many have cell phones, not all do, and so f/u isn't easy.

Education of the communities to let the women know who needs screened and where to go for screening is obviously something we need to do more of. We recently went out into a smaller health centers to try and do more education and bring the pap smears to them, referring anyone with an obvious high grade something to the hospital for immediate examination.

Many women are ashamed or refuse to be checked because they are bleeding and so for weeks or months their condition gets worse and worse and no one knows because they won't let anyone examine them or tell anyone about it. It is sad and many women suffer from cervical cancer and die each day here.

Maggie Sullivan Replied at 8:01 AM, 28 Dec 2011

Erin, thank you so much for sharing what your clinical situation is like. Is there a way to begin widespread VIA screening on women between 30-55 years old? That way, you will increase your chances of identifying cervical changes before women become symptomatic. It is usually recommended that asymptomatic women with a negative VIA result return in 3 years. Women with a positive VIA or symptoms return in 1 year. It is a great benefit that you already have VIA/cryo up and running. I would strongly advocate for widespread VIA screening, rather than only using it for women who have abnormal bimanual/speculum exams. I agree that it is important for education to occur simultaneously. Also, is there any way to solicit ideas from the women about what would make the exams less embarrassing? In some situations, we have found that bringing a female relative/close friend or the husband helps to make the patient feel more comfortable. In the process of community education, ideas from the women in your area could be solicited. Please continue to let us know of any questions or challenges you may have.

Erin Meier Replied at 3:55 PM, 28 Dec 2011

Maggie - We see so much cervical cancer before the age of 30, that waiting until 30 to do screening is not an option. Women here are dying of advanced cervical cancer before the age of 30 all the time. Anyone here of childbearing age is at risk for cervical cancer, most likely due to polygamy and multiple sexual partners. I try and send anyone who has any sort of pelvic complaint to get screened, but since I work at the hospital, I am only seeing a small population of people. So more outreaches into the communities and education by primary health care and community based outreaches, are going to be important.

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.