Every year there are approximately 16,000 new cases of cervical cancer in Brazil. Novel screening technologies may reduce this number by expanding the population coverage but also by improving the detection rate of precursor lesions. We aimed to evaluate human papillomaviruses (HPV)-DNA testing in the context of routine cervical cancer screening in the public health system of the city of São Paulo, Brazil. Women participating in the primary screening program were invited to enroll. Liquid-based cytology samples were collected and cytology and Hr-HPV DNA testing were performed in parallel. Cytologists were blind to HPV results. Women older than 24 years with a positive high-risk HPV test and/or cytology class ! ASC-US were referred to colposcopy. From December 2014 to December 2016, 16,102 women joined the study. High-risk human papilloma-virus (HR HPV) DNA prevalence was 14.9%, whereas cytologic abnormalities were found in 7.2% of the women. Per protocol, 1,592 Hr-HPV þ women, in addition to 72 patients with cytologic classification > lowgrade squamous intraepithelial lesion (LSIL) were referred. A total of 80 cervical intraepithelial neoplasia (CIN2 þ) cases were diagnosed, 79 were Hr-HPV DNA þ and 18 had normal cytology. Hr-HPV DNA detected a significant number of patients with premalignant lesions missed by cytology and all 16 CIN3 þ cases were Hr-HPV DNA þ. HPV genotyping may be useful in the management of Hr-HPV þ women, reducing the burden of colposcopic referral for those harboring genotypes with a weaker association to CIN3 þ. Use of HPV-DNA testing was shown to be feasible and advantageous over current cytologic screening in the public health system.
Objective To investigate factors associated with colposcopy attendance in HPV‐positive women in São Paulo, Brazil. Methods We analyzed data from a prospective cohort of women positive for high‐risk HPV (hr‐HPV) undergoing cervical cancer screening in primary care services in São Paulo, Brazil. Non‐pregnant women attending routine screening between December 2014 and March 2016 were offered an hr‐HPV test, and those testing positive and aged 25 years or older were invited for colposcopy. Sociodemographic information was recorded at study enrollment. We compared variables between women who did and did not attend colposcopy within a logistic regression framework. Results Of 1537 hr‐HPV‐positive women, 1235 (80.4%) attended for colposcopy, with a median time from primary test to colposcopy of 132 days. Younger age (P<0.001) and concurrent negative cytology results (P=0.025) were associated with lower attendance. Women registered at units providing both the primary test and colposcopy were more likely to attend than those at units making external referrals (788/862 [91.4%] versus 447/675 [66.2%], P<0.001). Conclusion Non‐attendance for colposcopy may limit the success of future screening programs based on hr‐HPV testing in Brazil. Transfer of colposcopy services to primary care is a simple and effective facilitator of attendance.
Objective: The aim of this study was to compare the performance of the current conventional Pap smear with liquid-based cytology (LBC) preparations. Study Design: Women routinely undergoing their cytopathological and histopathological examinations at Fundação Oncocentro de São Paulo (FOSP) were recruited for LBC. Conventional smears were analyzed from women from other areas of the State of São Paulo with similar sociodemographic characteristics. Results: A total of 218,594 cases were analyzed, consisting of 206,999 conventional smears and 11,595 LBC. Among the conventional smears, 3.0% were of unsatisfactory preparation; conversely, unsatisfactory LBC preparations accounted for 0.3%. The ASC-H (atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion) frequency did not demonstrate any differences between the two methods. In contrast, the incidence of ASC-US (atypical squamous cells of undetermined significance) was almost twice as frequent between LBC and conventional smears, at 2.9 versus 1.6%, respectively. An equal percentage of high-grade squamous intraepithelial lesions were observed for the two methods, but not for low-grade squamous intraepithelial lesions, which were more significantly observed in LBC preparations than in conventional smears (2.2 vs. 0.7%). The index of positivity was importantly enhanced from 3.0% (conventional smears) to 5.7% (LBC). Conclusions: LBC performed better than conventional smears, and we are truly confident that LBC can improve public health strategies aimed at reducing cervical lesions through prevention programs.
Our data indicate that cytology interpreted with prior knowledge of the HPV status provides higher sensitivity for CIN 2+ lesions while marginally reducing the overall specificity compared with HPV status blinded cytology.
Cervical cancer screening is a multistage process, therefore access to both the primary test and subsequent diagnostic procedures is essential. Considering women undergoing screening on the public health system in the State of São Paulo, Brazil, we aimed to estimate the proportion of women accessing colposcopy within six months of an abnormal smear result. We retrieved records from two administrative databases, the Information System on Uterine Cervical Cancer (SISCOLO) that contains smear results and the Outpatient Information System of the Brazilian Unified National Health System (SIA/SUS) that records colposcopies. A reference cohort consisted of women, aged 25 years or older, with an abnormal smear result between May 1, 2014, and June 30, 2014. We excluded prevalent cases. We linked the reference cohort and records in the SIA/SUS extending to December 31, 2014. After excluding prevalent cases, 1,761 women with abnormal cytology results were left. A total of 700 (39.8%) women were linked to a colposcopy record within the follow-up period; this dropped to 671 (38.1%) women when follow-up was censored at six months. We could notice a slightly higher attendance in women living in the metropolitan region of São Paulo compared with residents of the rest of the state. We found no association between colposcopy attendance and age or cytology class. These results emphasize that access to colposcopy in the public health system in São Paulo is limited. This compromises the quality of screening, and the issue needs to be prioritized in service planning.
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