| 1. |
- Alfonzo, Emilia, et al.
(författare)
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Accuracy of colposcopy in a Swedish screening program
- 2023
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Ingår i: Acta Obstetricia Et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 102:5, s. 549-555
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Tidskriftsartikel (refereegranskat)abstract
- IntroductionSensitivity and specificity of colposcopy vary greatly between studies and efficacy in clinical studies seldom corresponds with effectiveness in a real-life setting. It is unclear whether colposcopists' experience affects assessment; studies show divergent results. The study's objective was to investigate the accuracy of colposcopies in the Swedish screening program, the variability in colposcopists' assessments and whether degree of experience affects accuracy in a routine setting. Material and methodsCross-sectional register study. All colposcopic assessments with a concomitant histopathological sample from women aged at least 18 years, performed between 1999 and September 2020 in Sweden. The main outcome measure was accuracy. The accuracy of colposcopic assessments was calculated as overall agreement with linked biopsies, with three outcomes: Normal vs Atypical, Normal vs Low-Grade Atypical vs High-Grade Atypical, and Non-High-Grade Atypical vs High-Grade Atypical. A time-trend analysis was performed. The accuracy of identifiable colposcopists related to experience was analyzed. ResultsIn total, 82 289 colposcopic assessments with linked biopsies were included for analysis of the outcome Normal vs Atypical; average accuracy was 63%. Overrating colposcopic findings was four times more common than underrating. No time trend in accuracy was noted during the study period. Accuracy in distinguishing High-Grade from Non-High-Grade lesions was better: 76%. Among identifiable colposcopists, overall accuracy was 67%. Some had significantly better accuracy than others, but no correlation with experience was found. ConclusionsColposcopy, including in a referral setting, has low accuracy in distinguishing Normal from Atypical. Increased experience alone does not lead to improvement. This is supported by the substantial differences in performance between colposcopists.
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| 2. |
- Alfonzo, Emilia
(författare)
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Cervical and vaginal cancer - aspects on risk factors, prevention and treatment
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Participation in screening is associated with a major risk reduction in cervical cancer, but there is a lack of knowledge on whether the cost to the individual has an effect on the participation rate. Women with abnormal findings at screenings are referred for colposcopy. The use of the Swedescore scoring system is recommended by the Swedish national guidelines for cervical cancer prevention. There is, however, a lack of effectiveness studies evaluating this assessment. Previous studies have shown that women with cervical high-grade lesions have an increased risk for vaginal cancer, but there is a knowledge gap regarding the risk for hysterectomised women with and without risk factors. Women with early-stage cervical cancer are treated with radical hysterectomy, which can be performed via open or minimally invasive surgery (MIS). Inferior oncologic results of MIS have been reported in international studies, which emphasises the need for further assessment of the technique’s oncological safety.Aims: To study factors influencing the prevention of cervical and vaginal cancer by means of the screening programme for cervical cancer and to evaluate surgical treatment modalities for early-stage cervical cancer.Material and methods: Paper I was a randomised controlled trial (RCT) performed on female (n = 3124) residents of low-resource areas of Gothenburg in 2013. The intervention group did not have a fee, and the control group had the standard fee. Attendance was defined as registered cytological smear within three months of invitation. In paper II, population-based register data from the National Patient Register and the Swedish Cancer Register were used in a cohort study design 1987–2011. The cohort was divided into four groups: hysterectomised with benign cervical history, hysterectomised with a history of cervical intraepithelial lesion grade 3 (CIN3), hysterectomised with prevalent CIN at surgery and non-hysterectomised. The main outcome was vaginal cancer. Paper III was a cross-sectional study linking data from the Swedish National Cervical Screening Registry (NKCx) with histological samples and a Swedescore assessment and/or colposcopic assessment by identifiable colposcopists. In Paper IV, five-year overall survival (OS) and disease-free survival (DFS) were assessed in a population-based cohort study that included all Swedish women with IA1-IB1 cervical cancer treated with radical hysterectomy from 2011 to 2017. The Swedish Quality Register for Gynecological Cancer (SQRGC) was used for identification. Results: Paper I: No difference in attendance was noted between the intervention and control groups (RR=0.93 95% CI 0.83-1.02). Nor were there any differences according to previous participation or non-participation or between the districts. Paper II: 898 vaginal cancers were included. Women with prevalent CIN at hysterectomy had a high incidence rate (IR 51.3/100 000 95% CI 34.4-76.5), followed by women with CIN3 history (IR 17.1/100 000 95% CI 12.5-23.4). Paper III: 11 317 colposcopic assessments by Swedescore were included. Sensitivity at Swedescore ≥2 was 97.5%, and the negative predictive value (NPV) was 90.2%. Specificity at ≥8 was 93.3%, and the positive predictive value (PPV) was 60.1%. Area under the ROC curve (AUC) = 0.71. In total, 24 362 colposcopies with identifiable colposcopists were analysed for accuracy. The variability in accuracy differed significantly (p-value <0.001), no effect of experience was noted (k= 0.0024). Paper IV: In total, 864 women, 236 open and 628 robotic radical hysterectomies were identified and included. There was no difference in five-year OS between groups (Hazard Ratio (HR) 1.00; 95% CI 0.50-2.01) or DFS (HR 1.08 95% CI 0.66-1.78). Conclusions: Abolishment of a fee in low-resource settings did not increase attendance. Surveillance should be offered to hysterectomised women with prevalent CIN since their risk of vaginal cancer is elevated. Abstaining from biopsy is not recommended at any Swedescore step; a referral smear should be taken into consideration before “see and treat” to lower the risk for overtreatment. The experience of colposcopists did not affect accuracy. Long-term oncological outcomes did not differ between open and robotic radical hysterectomies.
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| 3. |
- Alfonzo, Emilia, et al.
(författare)
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Colposcopic assessment by Swedescore, evaluation of effectiveness in the Swedish screening programme: a cross-sectional study.
- 2022
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Ingår i: BJOG : an international journal of obstetrics and gynaecology. - : Wiley. - 1471-0528 .- 1470-0328. ; 129:8, s. 1261-1267
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Tidskriftsartikel (refereegranskat)abstract
- To evaluate the effectiveness and performance of Swedescore in the Swedish screening programme.Cross-sectional register study.All Swedish women aged over 18years with a colposcopic assessment linked to a biopsy in the Swedish National Cervical Screening Registry, 2015-20.Colposcopies with Swedescore were compared with the histopathological diagnosis of cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The respective influence of cytology and human papillomavirus (HPV) testing, at referral for colposcopy and concurrently with colposcopy, were investigated in regression models.CIN2+.A total of 11317 colposcopic assessments with Swedescore were included. Odds ratios for CIN2+ increased for every step in the Swedescore scale. At Swedescore ≥0-1, the proportion of CIN2+ was 9.8%. At Swedescore ≥8, the specificity was 93.3% and the positive predictive value was 60.1%, Area under the receiver operating characteristics curve (AUC) was 0.71. If the smear had been abnormal at referral, a normal colposcopy (Swedescore 0-1) was still associated with a CIN2+ risk of more than 5%. In the regression model, cytology and HPV had higher odds ratio for CIN2+ than colposcopy; the combination resulted in an AUC of 0.88.Swedescore works well in a routine clinical setting but colposcopy assessed with Swedescore was inferior to that reported in previous clinical studies. No safe cutoff level was identified for refraining from biopsy. See-and-treat at Swedescore 8-10 is feasible only if referral cytology showed high-grade squamous intraepithelial lesion.No safe cutoff level for refraining from biopsy nor for see-and-treat with Swedescore.
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| 4. |
- Alfonzo, Emilia, et al.
(författare)
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Effect of Fee on Cervical Cancer Screening Attendance-ScreenFee, a Swedish Population-Based Randomised Trial
- 2016
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Ingår i: Plos One. - : Public Library of Science (PLoS). - 1932-6203. ; 11:3
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Tidskriftsartikel (refereegranskat)abstract
- Background Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme. Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (approximate to 11 (sic)). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out. Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking. Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.
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| 5. |
- Alfonzo, Emilia, et al.
(författare)
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No survival difference between robotic and open radical hysterectomy for women with early-stage cervical cancer: results from a nationwide population-based cohort study
- 2019
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Ingår i: European Journal of Cancer. - : Elsevier BV. - 0959-8049 .- 1879-0852. ; 116, s. 169-177
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: The aim of the study was to compare overall survival (OS) and disease-free survival (DFS) after open and robotic radical hysterectomy for early-stage cervical cancer. Patients and methods: This was a nationwide population-based cohort study on all women with cervical cancer stage IA1-IB of squamous, adenocarcinoma or adenosquamous histological subtypes, from January 2011 to December 2017, for whom radical hysterectomy was performed. The Swedish Quality Register of Gynaecologic Cancer was used for identification. To ensure quality and conformity of data and to disclose patients not yet registered, hospital registries were reviewed and validated. Cox and propensity score regression analysis and univariable and multivariable regression analysis were performed in regard to OS and DFS. Results: There were 864 women (236 open and 628 robotic) included in the study. The 5-year OS was 92% and 94% and DFS was 84% and 88% for the open and robotic cohorts, respectively. The recurrence pattern was similar in both groups. Using propensity score analysis and matched cohorts of 232 women in each surgical group, no significant differences were seen in survival: 5-year OS of 92% in both groups (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.50–2.01) and DFS of 85% vs 84% in the open and robotic cohort, respectively (HR, 1.08; 95% CI, 0.66–1.78). In univariable and multivariable analysis with OS as the end-point, no significant factors were found, and in regard to DFS, tumour size (p < 0.001) and grade 3 (p = 0.02) were found as independent significant risk factors. Conclusion: In a complete nationwide population-based cohort, where radical hysterectomy for early-stage cervical cancer is highly centralised, neither long-term survival nor pattern of recurrence differed significantly between open and robotic surgery. © 2019 The Authors
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| 6. |
- Alfonzo, Emilia, et al.
(författare)
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Risk of vaginal cancer among hysterectomised women with cervical intraepithelial neoplasia: a population-based national cohort study.
- 2020
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Ingår i: BJOG : an international journal of obstetrics and gynaecology. - : Wiley. - 1471-0528 .- 1470-0328. ; 127:4, s. 448-454
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Tidskriftsartikel (refereegranskat)abstract
- To study the risk of vaginal cancer among hysterectomised women with and without CIN.Population-based national cohort study.All Swedish women, five million in total, aged 20 and up, 1987-2011 using national registries.The study cohort was subdivided into four exposure groups: hysterectomised with no previous history of CIN3 and without prevalent CIN at hysterectomy; hysterectomised with a history of CIN3/adenocarcinoma in situ (AIS); hysterectomised with prevalent CIN at hysterectomy; non-hysterectomised.Vaginal cancer.We identified 898 incident cases of vaginal cancer.Women with prevalent CIN at hysterectomy and those with CIN3/AIS history had incidence rates (IR) of vaginal cancer: 51.3 (34.3-76.5) and 17.1 (12.5-23-4) per 100000, respectively. Age-adjusted IR-ratios (IRRs) compared to hysterectomised with benign cervical history, were 21.0 (13.4-32.9) and 5.81(4.00-8.43), respectively. IR for non-hysterectomised women was 0.87 (0.81-0.93) and IRR 0.37 (0.30-0.46). In hysterectomised with prevalent CIN, the IR remained high after 15 years of follow-up: 65.7 (21.2-203.6).Our findings suggest that hysterectomised women with prevalent CIN at surgery should be offered surveillance. Hysterectomised women without the studied risk factors have a more than doubled risk of contracting vaginal cancer compared with non-hysterectomised women in the general population. Still, the incidence rate does not justify screening.
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| 7. |
- Dahm-Kähler, Pernilla, 1964, et al.
(författare)
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Uterus transplantation for fertility preservation in patients with gynecologic cancer
- 2021
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Ingår i: International Journal of Gynecological Cancer. - : BMJ. - 1048-891X .- 1525-1438. ; 31:3, s. 371-378
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Tidskriftsartikel (refereegranskat)abstract
- Cervical and endometrial cancer may impact women interested in future fertility in approximately 5-25% of cases. The recommended treatment for patients with early stage disease is hysterectomy and/or radiation leading to infertility. This is referred to as absolute uterine factor infertility. Such infertility was considered untreatable until 2014, when the first child was born after uterus transplantation. Thereafter, multiple births have been reported, mainly from women with Mayer-Rokitansky-Küster-Hauser syndrome, with congenital uterine absence, although also from a patient with iatrogenic uterine factor infertility caused by radical hysterectomy secondary to an early stage cervical cancer 7 years before uterus transplantation. A live birth after uterus transplantation may be considered promising for many who may not otherwise have this option. Uterus transplantation is a complex process including careful patient selection in both recipients and donors, in vitro fertilization, and complex surgery in the organ procurement procedure including harvesting the vessel pedicles with the thin-walled veins. Thereafter, the transplantation surgery with anastomosis to ensure optimal blood inflow and outflow of the transplanted organ. Knowledge regarding immunosuppression and pregnancy is essential. Lastly there is the hysterectomy component as the uterus must be removed. Multidisciplinary teams working closely are essential to achieve successful uterus transplantation and, ultimately, delivery of a healthy child. Both the living and deceased donor concept may be considered and we address both the advantages and disadvantages. This review summarizes the animal research thus far published on uterus transplantation, the suggested recipient selections including former gynecologic cancer patients, the living and deceased donor uterus transplantation concepts with reported results, and updated fertility outcomes. © IGCS and ESGO 2021. Re-use permitted under CC BY. Published by BMJ.
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| 8. |
- Ekdahl, Linnea, et al.
(författare)
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Increased Institutional Surgical Experience in Robot-Assisted Radical Hysterectomy for Early Stage Cervical Cancer Reduces Recurrence Rate: Results from a Nationwide Study
- 2020
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Ingår i: JOURNAL OF CLINICAL MEDICINE. - : MDPI AG. - 2077-0383. ; 9:11
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to evaluate the impact of institutional surgical experience on recurrence following robotic radical hysterectomy (RRH) for early stage cervical cancer. All women in Sweden who underwent an RRH for stage IA2-IB1 cervical cancer at tertiary referral centers from its implementation in December 2005 until June 2017 were identified using a Swedish nationwide register and local hospital registers. Registry data were controlled by a chart review of all women. Recurrence rates and patterns of recurrence were compared between early and late (<= 50 vs. >50 procedures) institutional series. Six hundred and thirty-five women were included. Regression analysis identified a lower risk of recurrence with increased experience but without a clear cut off level. Among the 489 women who did not receive adjuvant radio chemotherapy (RC-T), the rate of recurrence was 3.6% in the experienced cohort (>50 procedures) compared to 9.3% in the introductory cohort (p < 0.05). This was also seen in tumors < 2 cm regardless of RC-T (p < 0.05), whereas no difference in recurrence was seen when analyzing all women receiving RC-T. In conclusion, the rate of recurrence following RRH for early stage cervical cancer decreased with increased institutional surgical experience, in tumors < 2 cm and in women who did not receive adjuvant RC-T.
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| 9. |
- Wenzel, H. H. B., et al.
(författare)
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A federated approach to identify women with early-stage cervical cancer at low risk of lymph node metastases
- 2023
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Ingår i: European Journal of Cancer. - : Elsevier BV. - 0959-8049 .- 1879-0852. ; 185, s. 61-68
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Lymph node metastases (pN+) in presumed early-stage cervical cancer negatively impact prognosis. Using federated learning, we aimed to develop a tool to identify a group of women at low risk of pN+, to guide the shared decision-making process concerning the extent of lymph node dissection.Methods: Women with cervical cancer between 2005 and 2020 were identified retrospectively from population-based registries: the Danish Gynaecological Cancer Database, Swedish Quality Registry for Gynaecologic Cancer and Netherlands Cancer Registry. Inclusion cri-teria were: squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma; The International Federation of Gynecology and Obstetrics 2009 IA2, IB1 and IIA1; treatment with radical hysterectomy and pelvic lymph node assessment. We applied privacy-preserving federated logistic regression to identify risk factors of pN+. Significant factors were used to stratify the risk of pN+. Results: We included 3606 women (pN+ 11%). The most important risk factors of pN+ were lymphovascular space invasion (LVSI) (odds ratio [OR] 5.16, 95% confidence interval [CI], 4.59-5.79), tumour size 21-40 mm (OR 2.14, 95% CI, 1.89-2.43) and depth of invasion > 10 mm (OR 1.81, 95% CI, 1.59-2.08). A group of 1469 women (41%)-with tumours without LVSI, tumour size 520 mm, and depth of invasion 510 mm-had a very low risk of pN + (2.4%, 95% CI, 1.7-3.3%). Conclusion: Early-stage cervical cancer without LVSI, a tumour size 520 mm and depth of invasion 510 mm, confers a low risk of pN+. Based on an international privacy-preserving analysis, we developed a useful tool to guide the shared decision-making process regarding lymph node dissection.& COPY; 2023 Elsevier Ltd. All rights reserved.
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