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I165 NEW SCREENING ALGORITHMS FOR POPULATION-BASED PROGRAMS
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Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
year. The incidence of breast cancer is also increasing in Peru, and due to the lack of access to screening, most cases are diagnosed at advanced stages. Even though the incidence of breast cancer is much higher in developed countries, the burden of disease is disproportionally increasing in low-resource countries where the survival rates are much lower. In some parts of Africa women newly diagnosed with breast cancer have 12% likelihood to survive 5 years, compared to 65% in Peru and almost 80% in the United States. The main factors for improving the survival of women with breast cancer are adequate access to screening and diagnosis at early stages, and use of adjuvant therapies. Early detection of breast cancer is important because the cost and success of treatment is directly related to the stage of disease at the time of diagnosis. Unfortunately mammography is not widely available in most developing countries where the scarce resources for screening are limited to some urban areas. Affordable screening, diagnostic and treatment options, and resource-appropriate guidelines offer new opportunities to reach underserved populations with lifesaving screening and treatment approaches that are effective and sustainable. I165 NEW SCREENING ALGORITHMS FOR POPULATION-BASED PROGRAMS J. Jeronimo New cervical cancer screening strategies have been developed in the last decade; some of them are suitable and affordable for developing countries. These new approaches open more opportunities for expanding cervical cancer screening coverage, but create a need to develop comprehensive algorithms that are optimized for different scenarios in developing countries. Between 2009 and 2012 PATH developed field studies using different screening options, including VIA, Pap smear, careHPV™, E6 testing (for genotypes 16/18/45), and DNA genotyping for HPV strains 16/18/45. CareHPV™ testing was done using both a vaginal sample self-collected by women without pelvic evaluation and a cervical sample collected by a health care provider. These studies involved the enrollment of approximately 27,500 women from India (Hyderabad and Delhi), China, Nicaragua, and Uganda. All the evaluations and testing were done using the public health system available in those countries. Colposcopy and biopsy were done for any positive screening result and 10% of randomly-selected women with negative results. Results from these studies show that the best sensitivity for detection of CIN2+ was achieved by careHPV™ using providercollected cervical samples (70–95%), followed by careHPV™ in selfcollected vaginal samples (65–85%). Sensitivity of VIA ranged from 47 to 65%, Pap smear from 40 to 76%, and for the E6 test was 64%. We modeled different screening algorithms starting with careHPV™ as the primary screening tool. When either VIA or Pap smear is used as a second test for HPV+ women, the final sensitivity decreases by half; it is important to consider other possible screening algorithms. I166 THE UTILITY OF COLPOSCOPY IN THE MANAGEMENT OF WOMEN WITH ABNORMAL SCREENING TESTS J. Jeronimo New cervical cancer screening technologies are being developed, bringing changes to the strategies used for the last several decades. In addition, we have population-based programs using HPV vaccines that will eventually reduce the rates of cervical cancer and its precursors within the next decades. Colposcopy is still the main tool for ruling out invasive cancer and guiding the collection of diagnostic biopsies. For decades, cytology was the only screening test for cervical cancer screening and the main test triggering referrals to colposcopy clinics; but with the advent of
new highly sensitive technologies, cases of pre-cancer and lesions are detected much earlier and at smaller sizes. The accuracy of colposcopy has been questioned and options have been proposed in order to increase the sensitivity for detecting CIN2+ cases. These include: taking additional biopsies from different parts of the worst-looking lesion; taking additional biopsies from other abnormal area or areas; or even taking random biopsies from colposcopically normal areas of the epithelium. Fortunately, more research has been done and now we understand that taking additional biopsies from colposcopically abnormal areas could increase the accuracy of colposcopy for detecting CIN2+. Colposcopy is evolving and a new nomenclature has been recently released by the International Federation of Cervical Pathology and Colposcopy (IFCPC) making it simpler and easier to understand. New research is needed to validate whether the new nomenclature is more replicable and accurate, since colposcopy will still a pivotal role in the evaluation of women with abnormalities of the uterine cervix. I167 WHAT WE DON’T KNOW ABOUT ENDOMETRIOSIS: RESULTS FROM A GLOBAL CONSENSUS MEETING N. Johnson. University of Auckland and Repromed Auckland, New Zealand Background: An international consensus meeting on the management of endometriosis, organized by the World Endometriosis Society and attended by experts representing 31 national and international, medical and non-medical organizations, took place on 8 September 2011. Methods: From May to September 2011, a consensus process was followed, to analyze and categorize evidence concerning the management of endometriosis. The consensus meeting took place on 8 September 2011 in Montpellier, France, association with the 2011 World Congress on Endometriosis. A further process was followed after the meeting, including a formal survey of participants, then the consensus statement was drafted, modified and agreed upon by the participants of the consensus meeting. Results: Sixty five consensus statements were developed for which there was majority support for the statement and the categorization of the strength of the statement. In our post-meeting survey, none of the statements made achieved 100% agreement without expression of a caveat about either the statement or the strength of the statement; only seven of our 65 consensus statements were associated with a 0% disagreement rate from the survey respondents. Many of our statements were based on weak evidence; indeed in the case of our good practice points, on no research evidence; however such statements could still be associated with a strong consensus amongst the experts. Some key issues, where research evidence to inform practice remains sparse, are: management of adolescents who have, or might have, endometriosis as well as intervention strategies in the younger age group designed to prevent endometriosis; lifestyle and dietary interventions; standardization of long term strategies for prevention of recurrent endometriosis; clarification of management strategies, both surgical and medical, for women with deep infiltrating endometriosis; development of standards of experience and expertise required for surgeons undertaking advanced laparoscopic endometriosis surgery; standardization of centers/networks of expertise with regard to definition, accreditation and longevity; development of models of care in low resource settings. Conclusion: An attempt to reach consensus on the management of endometriosis has unearthed many areas where research findings are insufficient to inform practice. Research should be geared towards interventional strategies, ideally simple and low cost, designed to bring maximum beneficial impact for a minimal treatment burden for women with endometriosis.
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
year. The incidence of breast cancer is also increasing in Peru, and due to the lack of access to screening, most cases are diagnosed at advanced stages. Even though the incidence of breast cancer is much higher in developed countries, the burden of disease is disproportionally increasing in low-resource countries where the survival rates are much lower. In some parts of Africa women newly diagnosed with breast cancer have 12% likelihood to survive 5 years, compared to 65% in Peru and almost 80% in the United States. The main factors for improving the survival of women with breast cancer are adequate access to screening and diagnosis at early stages, and use of adjuvant therapies. Early detection of breast cancer is important because the cost and success of treatment is directly related to the stage of disease at the time of diagnosis. Unfortunately mammography is not widely available in most developing countries where the scarce resources for screening are limited to some urban areas. Affordable screening, diagnostic and treatment options, and resource-appropriate guidelines offer new opportunities to reach underserved populations with lifesaving screening and treatment approaches that are effective and sustainable. I165 NEW SCREENING ALGORITHMS FOR POPULATION-BASED PROGRAMS J. Jeronimo New cervical cancer screening strategies have been developed in the last decade; some of them are suitable and affordable for developing countries. These new approaches open more opportunities for expanding cervical cancer screening coverage, but create a need to develop comprehensive algorithms that are optimized for different scenarios in developing countries. Between 2009 and 2012 PATH developed field studies using different screening options, including VIA, Pap smear, careHPV™, E6 testing (for genotypes 16/18/45), and DNA genotyping for HPV strains 16/18/45. CareHPV™ testing was done using both a vaginal sample self-collected by women without pelvic evaluation and a cervical sample collected by a health care provider. These studies involved the enrollment of approximately 27,500 women from India (Hyderabad and Delhi), China, Nicaragua, and Uganda. All the evaluations and testing were done using the public health system available in those countries. Colposcopy and biopsy were done for any positive screening result and 10% of randomly-selected women with negative results. Results from these studies show that the best sensitivity for detection of CIN2+ was achieved by careHPV™ using providercollected cervical samples (70–95%), followed by careHPV™ in selfcollected vaginal samples (65–85%). Sensitivity of VIA ranged from 47 to 65%, Pap smear from 40 to 76%, and for the E6 test was 64%. We modeled different screening algorithms starting with careHPV™ as the primary screening tool. When either VIA or Pap smear is used as a second test for HPV+ women, the final sensitivity decreases by half; it is important to consider other possible screening algorithms. I166 THE UTILITY OF COLPOSCOPY IN THE MANAGEMENT OF WOMEN WITH ABNORMAL SCREENING TESTS J. Jeronimo New cervical cancer screening technologies are being developed, bringing changes to the strategies used for the last several decades. In addition, we have population-based programs using HPV vaccines that will eventually reduce the rates of cervical cancer and its precursors within the next decades. Colposcopy is still the main tool for ruling out invasive cancer and guiding the collection of diagnostic biopsies. For decades, cytology was the only screening test for cervical cancer screening and the main test triggering referrals to colposcopy clinics; but with the advent of
new highly sensitive technologies, cases of pre-cancer and lesions are detected much earlier and at smaller sizes. The accuracy of colposcopy has been questioned and options have been proposed in order to increase the sensitivity for detecting CIN2+ cases. These include: taking additional biopsies from different parts of the worst-looking lesion; taking additional biopsies from other abnormal area or areas; or even taking random biopsies from colposcopically normal areas of the epithelium. Fortunately, more research has been done and now we understand that taking additional biopsies from colposcopically abnormal areas could increase the accuracy of colposcopy for detecting CIN2+. Colposcopy is evolving and a new nomenclature has been recently released by the International Federation of Cervical Pathology and Colposcopy (IFCPC) making it simpler and easier to understand. New research is needed to validate whether the new nomenclature is more replicable and accurate, since colposcopy will still a pivotal role in the evaluation of women with abnormalities of the uterine cervix. I167 WHAT WE DON’T KNOW ABOUT ENDOMETRIOSIS: RESULTS FROM A GLOBAL CONSENSUS MEETING N. Johnson. University of Auckland and Repromed Auckland, New Zealand Background: An international consensus meeting on the management of endometriosis, organized by the World Endometriosis Society and attended by experts representing 31 national and international, medical and non-medical organizations, took place on 8 September 2011. Methods: From May to September 2011, a consensus process was followed, to analyze and categorize evidence concerning the management of endometriosis. The consensus meeting took place on 8 September 2011 in Montpellier, France, association with the 2011 World Congress on Endometriosis. A further process was followed after the meeting, including a formal survey of participants, then the consensus statement was drafted, modified and agreed upon by the participants of the consensus meeting. Results: Sixty five consensus statements were developed for which there was majority support for the statement and the categorization of the strength of the statement. In our post-meeting survey, none of the statements made achieved 100% agreement without expression of a caveat about either the statement or the strength of the statement; only seven of our 65 consensus statements were associated with a 0% disagreement rate from the survey respondents. Many of our statements were based on weak evidence; indeed in the case of our good practice points, on no research evidence; however such statements could still be associated with a strong consensus amongst the experts. Some key issues, where research evidence to inform practice remains sparse, are: management of adolescents who have, or might have, endometriosis as well as intervention strategies in the younger age group designed to prevent endometriosis; lifestyle and dietary interventions; standardization of long term strategies for prevention of recurrent endometriosis; clarification of management strategies, both surgical and medical, for women with deep infiltrating endometriosis; development of standards of experience and expertise required for surgeons undertaking advanced laparoscopic endometriosis surgery; standardization of centers/networks of expertise with regard to definition, accreditation and longevity; development of models of care in low resource settings. Conclusion: An attempt to reach consensus on the management of endometriosis has unearthed many areas where research findings are insufficient to inform practice. Research should be geared towards interventional strategies, ideally simple and low cost, designed to bring maximum beneficial impact for a minimal treatment burden for women with endometriosis.