The factors that determine participation in cervical cancer screening in the state of Morelos

OBJECTIVE: To determine the main factors associated to participation in an early detection program of cancer (DPC), in a population with a high cervical cancer (CC) mortality rate. MATERIAL AND METHODS: A population-based, cross-sectional study was performed in the state of Morelos, which included 3,197 women aged between 15 and 49 years, randomly selected from a household sample frame of the 33 municipalities of the state. RESULTS: Awareness of the utility of the Papanicolaou (Pap) test (OR 29.6, 95% CI 23.6-37) and a former history of gynecological symptoms (OR 1.7, 95% CI 1.2-2.4) predisposed to greater use of the DPC. Factors associated to the use of the Pap test were precedents of using one contraceptive (OR 1.4, 95% CI 1.1-1.8) or two or more contraceptives (OR 2.1, 95% CI 1.6-2.8). CONCLUSIONS: In the state of Morelos, Mexico, screening for cervical cancer is offered opportunistically in the context of health care use. Therefore, the precedent of using health care services is the main determining factor for use of the DPC program. These results reveal the need to design alternative strategies to promote participation among women who have no access to health services, since they constitute the population group at highest risk of developing CC.     

Risk factors for cervical cancer among HPV positive women in Mexico

OBJECTIVE: To identify factors that are associated with an increased risk of developing high-grade cervical intraepithelial neoplasia (CIN) or cancer among human papillomavirus (HPV)-positive women in Mexico. MATERIAL AND METHODS: A case-control study design was used. A total of 94 cases and 501 controls who met the study inclusion criteria were selected from the 7 732 women who participated in the Morelos HPV Study from May 1999 to June 2000. Risk factor information was obtained from interviews and from HPV viral load results. Odds ratios and 95 percent confidence intervals were estimated using unconditional multivariate regression. RESULTS: Increasing age, high viral load, a young age at first sexual intercourse, and a low socio-economic status are associated with an increased risk of disease among HPV-positive women. CONCLUSIONS: These results could have important implications for future screening activities in Mexico and other low resource countries.     

Assessment of HPV detection assays for use in cervical cancer screening programs

OBJECTIVE: Detection of high-risk human papillomavirus types (HPV) infection is an important tool in the screening of cervical cancer and triage of cytological abnormalities. The different techniques for detection of this cancer need to be contrasted and validated for use in population screening. MATERIAL AND METHODS: Cervical cell samples were collected from 166 women attending a dermatology clinic in Oviedo (Spain).We evaluated the performance of three different assays for VPH detection.The methods utilized were 1) In-house PCR-EIA using LI consensus primers MY09/ MY11, 2) A PCR-reverse line blot hybridization (PCR-LBH) that uses LI consensus PGMY primers. 3) Hybrid Capture 2. All assays were performed blinded. The kappa statistic was used to test for global agreement between assay pairs. RESULTS: HPV DNA was detected in 24,7%, 25,3% and 29,5% of the women, respective to the assay.The overall agreement between the in-house PCR, PCR-LBH and HC2 was (73.5%) with all kappa values between assay pairs exceeding 0.56 (p<0.001). CONCLUSION: The three HPV assays were equally accurate in estimating high-risk HPV prevalence and HPV-related lesions.The method for HPV detection must be decided depending on the goals of the search (screening, follow-up or molecular studies).     

绝经后妇女宫颈癌筛查的价值及方法的研究

目的探讨绝经后妇女宫颈癌筛查的价值和筛查方法的研究。方法对1278名研究对象进行醋酸肉眼直接观察（VIA）、随机巴氏涂片或液基细胞学检查（TCT）、随机人乳头瘤病毒（HPV）检测（HC—II方法）。按诊断标准结果阳性者行阴道镜检查与定位活检,筛查阴性者如自愿活检亦予以对照活检。结果病理检出CINⅠ9人,CINⅡ6人,CINⅢ5人。各种筛查方法灵敏度、阳性预测值、阴性预测值比较无统计学意义（P〉0．05）;特异度比较：VIA低于其余几项,巴氏涂片和TCT最高（两者间差异无统计学意义）,TCT、VIA联合巴氏涂片、HPV之间差异无统计学意义。结论开展对绝经后妇女宫颈癌的筛查十分有必要。应高度重视绝经后妇女HPV感染。VIA联合巴氏涂片适于在基层单位用于绝经后妇女宫颈癌的筛查。     

Increasing Access to Treatment for Chagas Disease: The Case of Morelos,Mexico

Chagas disease is a neglected vector-borne disease with an estimated prevalence of 1.1 million cases in Mexico. Recent research showed that access to treatment of Chagas disease is limited in Mexico, with < 0.5% of infected cases treated. This brief report used quantitative data from the Morelos Program on Chagas disease and qualitative analysis of key informant interviews to examine strategies to increase treatment access for infected patients in Morelos, Mexico. From 2007 to 2011, 263 (9.2%) of the registered cases of Chagas disease in Mexico occurred in Morelos. Among these, 152 (57.8%) were treated and 97.3% of those treated received benznidazole. The assessment finds that state officials decided to directly purchase benznidazole from the distributor to increase access and improve clinical quality of treatment of patients in their state. They also faced significant barriers, especially in regulation and health system organization, which limited efforts to make high quality treatment available.Chagas disease is a neglected vector-borne disease with a prevalence of 8–10 million cases globally, with an estimated 1.1 million cases in Mexico.^1,2 Recent research conducted in Mexico showed that access to treatment of Chagas disease is limited, with < 0.5% of those who are infected having received treatment in recent years, despite evidence of cost-savings with early diagnosis and treatment.^3,4 The research found multiple regulatory, organizational, and political barriers to treatment access at the national level in Mexico. This brief report uses both quantitative and qualitative analysis to show how the state of Morelos overcame these barriers in Mexico to increase access to treatment of Chagas disease in that state.Morelos has a population of just over 1.7 million inhabitants or about 1.6% of the Mexican total. Economically, Morelos ranked 21 out of 31 states by gross domestic product (GDP) in 2007. Geographically, it is located south of Mexico City, and is bordered by the states of Mexico, Puebla, and Guerrero. The national Program on Onchocerciasis, Leishmaniasis, and Chagas Disease, within the Mexican Secretary of Health''s National Center for the Prevention and Control of Diseases (CENAPRECE), is the unit responsible for establishing guidelines and coordinating national activities for Chagas disease control, including facilitating the donation and distribution of nifurtimox, often considered the second line therapeutic agent for Chagas disease.⁴ Within the state''s Secretary of Health, the state program on Chagas disease has the operational responsibility for prevention and control activities for this illness, and coordination with healthcare providers for procurement of medication, treatment, and follow-up of those who are infected. Neither benznidazole nor nifurtimox has received market authorization in Mexico from the national medicine regulatory body, called the Federal Commission for Protection against Health Risks (COFEPRIS). As such, they have historically not been included in the national formulary or the formulary of the Seguro Popular health insurance program. It is likely that the absence of a market authorization is one major reason for their exclusion from the formulary, though another possible reason is that the importance of treatment has only recently been acknowledged by the wider medical community.^5,6This report about the state of Morelos is part of a larger national study of Chagas disease in Mexico that consisted of 18 semi-structured in-depth interviews, among which eight interviews involved discussions of Morelos.⁴ The Morelos state program provided data on the number of cases diagnosed and treated. Contact with initial interviewees was established through in-country key informants and subsequent interviews were obtained through a snowball sampling method. For all processes described in the interviews, official reports and supporting documentation were requested. These documents, along with the published literature and other interview responses, were used in triangulating interview responses. The institutional review board (IRB) exemption was obtained from Harvard School of Public Health (Protocol no. 21514-101) and the National Institute for Public Health (INSP) located in Cuernavaca, Mexico. Oral informed consent was obtained from all interviewees. The data were analyzed according to the Flagship Framework for Pharmaceutical Policy Reform''s control knobs: regulation, payment, financing, organization, and persuasion.⁷ Here, we assess the approaches used in Morelos to procure and distribute benznidazole, organized according to the Flagship Framework for Pharmaceutical Policy Reform.     

The importance of psychosocial factors in the prevention of HPV infection and cervical cancer

This article presents a review of psychosocial factors associated with the primary and secondary prevention of cervical cancer. Current research evidence convincingly links the presence of the human papillomavirus (HPV) to the development of cervical cancer suggesting that bringing together knowledge from the Papanicolau smear screening and HPV infection research may help formulate a new approach that bridges primary and secondary prevention strategies. Bringing together these 2 areas of research involves an understanding of the psychosocial factors that underlie both. This review will specifically focus on 3 areas of psychosocial research: (1) sexual behaviours associated with HPV infection; (2) knowledge, attitudes and beliefs associated with Pap smear and HPV screening; and (3) the role of the medical provider in facilitating prevention activities.     

Improving cervical cancer screening rates in an urban HIV clinic

Human immunodeficiency virus (HIV)-infected women are at increased risk of invasive cervical cancer; however, screening rates remain low. The objectives of this study were to analyze a quality improvement intervention to increase cervical cancer screening rates in an urban academic HIV clinic and to identify factors associated with inadequate screening. Barriers to screening were identified by a multidisciplinary quality improvement committee at the Washington University Infectious Diseases clinic. Several strategies were developed to address these barriers. The years pre- and post-implementation were analyzed to examine the clinical impact of the intervention. A total of 422 women were seen in both the pre-implementation and post-implementation periods. In the pre-implementation period, 222 women (53%) underwent cervical cancer screening in the form of Papanicolaou (Pap) testing. In the post-implementation period, 318 women (75.3%) underwent cervical cancer screening (p < 0.01). Factors associated with lack of screening included fewer visits attended (pre: 4.2 ± 1.5; post: 3.4 ± 1.4; p < 0.01). A multidisciplinary quality improvement intervention was successful in overcoming barriers and increasing cervical cancer screening rates in an urban academic HIV clinic.     

薄层液基细胞学与人乳头瘤病毒联合检测在宫颈上皮病变筛查中的应用

目的 探讨薄层液基细胞学(TCT)与人乳头瘤病毒(HPV)联合检测在宫颈上皮病变筛查中的应用.方法 对在我院妇科门诊就诊和体检进行TCT联合HPV检测的妇女,选择单纯TCT阳性者121例为TCT组,单纯HPV阳性者169例为HPV组,两者均阳性者92例为TCT联合HPV组,三组均经阴道镜下取活检,以组织病理学为金标准,比较三组与组织病理学诊断的阳性预测值.分析TCT联合HPV检测双阳性与TCT和HPV单纯阳性在宫颈上皮病变筛查效果中有无差异.结果 TCT组、HPV组、TCT联合HPV组与组织病理学诊断的阳性预测值分7.02%、30.77%、75.00%.TCT联合HPV组与TCT组比较差异有统计学意义(χ2=7.40,P<0.05),TCT联合HPV组与HPV组比较差异有统计学意义(χ2=46.87,P<0.05).结论 TCT联合HPV检测筛查宫颈上皮病变明显优于TCT和HPV的单纯检测,是宫颈癌及癌前病变筛查较理想的方法.     

大肠癌筛选方法及有效性研究

一、背景 大肠癌是常见恶性肿瘤之一,全世界范围内大肠癌发病率男女均处于恶性肿瘤第3位。2003年美国大肠癌新发病例数和死亡率均居第3位。据国际癌症研究组织（IARC）提供数据显示亚洲地区,尤其经济发达地区其发病率也迅速增长。