TY - JOUR
T1 - High-risk human papillomavirus testing for cervical cancer screening in Uganda
T2 - Considering potential harms and benefits in a low-resource setting
AU - Sultanov, Marat
AU - Koot, Jaap A R
AU - de Bock, Geertruida H
AU - Greuter, Marcel J W
AU - Beltman, Jogchum J
AU - de Fouw, Marlieke
AU - de Zeeuw, Janine
AU - Kabukye, Johnblack
AU - Stekelenburg, Jelle
AU - van der Schans, Jurjen
N1 - Copyright: © 2024 Sultanov et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
PY - 2024/10/23
Y1 - 2024/10/23
N2 - OBJECTIVES: The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.METHODS: A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.RESULTS: Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.DISCUSSION: For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.
AB - OBJECTIVES: The World Health Organization supports both the screen-and-treat (ST) approach and the screen, triage and treat (STT) approach to cervical cancer screening using high-risk human papillomavirus (hrHPV) testing. For Uganda, the sequence of hrHPV-ST and hrHPV-STT could be similar, with visual inspection with acetic acid (VIA) after positive hrHPV tests in both. To consider potential tradeoffs (overtreatment in ST versus missed cancer cases in STT), we compared hrHPV-STT with VIA triage (STT-VIA), and STT with HPV 16/18 genotyping risk stratification, to hrHPV-ST for Uganda, in terms of overtreatment, cervical cancer incidence, and life years, for the general female population of Uganda.METHODS: A microsimulation model of cervical cancer was adapted. Incremental benefit-harm ratios of STT were calculated as ratios of prevented overtreatment to reduced life years, and to increased cancer cases. Additional scenarios with 20% difference in intra- and inter-screening follow-up between ST and STT were modeled.RESULTS: Both STT strategies resulted in life year losses on average compared to ST. STT-VIA prevented more overtreatment but led to increased cervical cancer incidence and life year losses. STT-G-VIA resulted in better harm-benefit ratios and additional costs. With better follow-up, STT prevented overtreatment and improved outcomes.DISCUSSION: For Uganda, the STT approach appears preferrable, if the screening sequences of hrHPV-based ST and STT are similar in practice. While VIA triage alone would reduce overtreatment the most, it could also result in more cancer cases. Risk stratification via genotyping could improve STT. Potential follow-up differences and resource availability should be considered by decision-makers when planning Uganda's hrHPV-based screening strategy.
KW - Humans
KW - Female
KW - Uterine Cervical Neoplasms/diagnosis
KW - Uganda/epidemiology
KW - Early Detection of Cancer/methods
KW - Papillomavirus Infections/diagnosis
KW - Adult
KW - Middle Aged
KW - Human papillomavirus 18/genetics
KW - Human papillomavirus 16/genetics
KW - Mass Screening/methods
KW - Human Papillomavirus Viruses
U2 - 10.1371/journal.pone.0312295
DO - 10.1371/journal.pone.0312295
M3 - Article
C2 - 39441790
SN - 1932-6203
VL - 19
JO - PLoS ONE
JF - PLoS ONE
IS - 10
M1 - e0312295
ER -