Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis

Kyrgiou, Maria; Athanasiou, Antonios; Paraskevaidi, Maria; Mitra, Anita; Kalliala, Ilkka; Martin‐Hirsch, Pierre L.; Arbyn, Marc; Bennett, Phillip R.; Paraskevaidis, Evangelos

doi:10.1136/bmj.i3633

Cited by 353 publications

(347 citation statements)

References 119 publications

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“…Uterine and cervical weakness impair their ability to support mechanical stresses induced by full-term pregnancy. Mechanical weakness is thought to contribute to PTB in women with uterine anomalies, previous cervical surgery, more than 3 prior abortions, or an interpregnancy interval of less than 6 months (3,(22)(23)(24). Multiple pregnancies can also cause over-distention of the uterus and release of pro-inflammatory cytokines, leading to contractions and P-PROM (7).…”

Section: Aetiology and Risk Factors For Ptbmentioning

confidence: 99%

The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women

et al. 2017

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Context: Preterm birth accounts for significant neonatal mortality and morbidity as well as substantial health costs. As our understanding of aetiology and risk factors for preterm birth increases, predictive tools and prophylactic interventions have been developed to improve maternal and fetal outcomes. These are effective, but require surveillance of asymptomatic high-risk women, as well as ultrasound and surgical expertise. This has led to the development of preterm birth surveillance clinics (PSCs), which pool these resources together and have changed the focus of care from reactive to predictive and preventative management. Methods: A literature review of the evidence surrounding the predictive tests (cervical length, fetal fibronectin, Actim Partus, Partosure) and prophylactic interventions (cerclage, progesterone, Arabin pessary, antibiotics, and steroids) for preterm birth to understand what preterm birth surveillance clinics do and how effective they are. Results: Measuring cervical length and fetal fibronectin levels are two of the most accurate predictive tests preterm birth, especially when used in combination. Other predictive tools like Actim Partus and Partosure are effective for symptomatic women, but their role in surveillance of asymptomatic women is unclear. Cervical cerclage is effective in reducing preterm birth in women with previous losses, but the role of progesterone and pessaries remains debated. Steroids remain one of the most effective antenatal intervention, but they need to be administered within a tight timeframe in order to confer maximal benefit. The role of PSCs in predicting the timing of birth and targeting women at highest risk to appropriate interventions is therefore crucial in optimizing care and improving outcomes. Conclusions: Nearly every step of management is still debated although many have a strong evidence-base and effective interventions do exist. The challenge is finding the optimal management pathway, and details of which populations benefit from which interventions need to be evaluated. While evidence continues to be collated, the poor outcomes of preterm birth and the multiple options available to reduce them justify preterm birth surveillance clinics being resourced.Keywords: Preterm Birth, Predictive, Fetal Fibronectin, Cervical Length, Cervical Cerclage ContextDefined as spontaneous or induced birth before 37+ 0 weeks' gestation, preterm birth (PTB) is responsible for significant perinatal morbidity and mortality. Preterm labour affects 11.1% of live births worldwide (1) and 7.6% of live births in England and Wales (2), but incidence is rising globally (3). PTB causes more than 3 million perinatal deaths a year (1) and causes increased risks of neurodevelopmental impairment, behavioural problems and respiratory diseases, which constitute significant health costs and decreased quality of life (4-6). MethodsThe primary research question our review is addressing is "what predictive tests and prophylactic interventions to preterm birth surveillance clini...

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Section: Aetiology and Risk Factors For Ptbmentioning

confidence: 99%

The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women

et al. 2017

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“…The general aim of this thesis is to inform decision-makers about the health benefits, resource use and cost-effectiveness of current and future CC screening policies in Norway. Specifically, the four papers in this thesis evaluate: (i) the short-term health and economic outcomes of using novel biomarkers to triage younger (i.e., aged [25][26][27][28][29][30][31][32][33] years) unvaccinated women with minor cervical cytological lesions, (ii) the most costeffective strategy to triage unvaccinated women with minor cervical cytological lesions, (iii) the trade-offs in health benefits and resource use associated with adopting primary HPV DNA testing strategies for unvaccinated women, and (iv) the most cost-effective CC screening strategies for women vaccinated against HPV-infections in adolescence.…”

Section: Acknowledgementsmentioning

confidence: 99%

“…Women may also experience anxiety from the procedure itself, or from awaiting and receiving test results. In addition, diagnostic colposcopy-directed biopsy may cause pain, bleeding, or discharge [29], and treatment of cervical precancer is associated with an increased risk of preterm birth and other adverse pregnancy outcomes [30,31]. The majority of precancers would never have progressed to cancer in the absence of treatment [22] yet available technologies cannot distinguish between precancers that will progress to CC from those likely to regress; consequently, CC screening involves some over-treatment.…”

Section: Principles and Aspects Of Cervical Cancer Screeningmentioning

confidence: 99%

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost‐effectiveness analysis

Pedersen

Sørbye

et al. 2016

BJOG

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Objective To evaluate the short‐term consequences and cost‐effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions. Design Model‐based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials. Setting Organised cervical cancer screening in Norway. Population Women aged 25–33 years with minor cervical cytological lesions detected at their primary screening test. Methods We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines. Main outcome measures The number of high‐grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost‐efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy. Results Five strategies were identified as cost‐efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA‐based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines. Conclusion Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision‐makers' and women's acceptance of additional screening procedures. Tweetable abstract Women with minor cervical lesions may be triaged more accurately and effectively using novel biomarkers.

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“…screening tests and between 300 and 900 excisional procedures (e.g., loop electrosurgical excision procedure or cone biopsy). 10 Furthermore, a systematic review and meta-analysis that assessed the effect of treatment for cervical intraepithelial neoplasia on obstetric outcomes 11 showed that cervical excisional procedures may increase the rate of preterm birth by about 5%, depending on the depth of excision, and raise the risk of perinatal death by about 0.2% in each subsequent pregnancy, yet the cumulative risk of cancer developing before age 30 years is less than 0.05%. In addition, diagnosis of cervical intraepitheleal neoplasia has substantial psychosocial impact, particularly for women with high-grade lesions.…”

Section: Key Pointsmentioning

confidence: 99%

Evidence that supports policies to delay cervical screening until after age 25 years

Dickinson

Niekerk

Popadiuk

2017

CMAJ

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New guidelines for cervical screening from Alberta 1 and British Columbia 2 recommend increasing the starting age from 21 to 25 years. These guidelines follow the recommendations published by the Canadian Task Force on Preventative Health Care in 2013, 3 and are similar to many other highincome countries. Cervical cancer mostly has a long natural history and, consequently, is uncommon in women under age 25 years. Cervical screening among this age group has minimal impact on rates of carcinoma but does lead to overdiagnosis and overtreatment of precancerous lesions that are destined to regress or not progress to cancer until later. Physicians may be concerned that delaying screening for cervical cancer will lead to reduced testing for sexually transmitted infection and too few pelvic examinations. However, delaying the onset of cervical screening for women at average risk until after age 25 years strikes the best balance between screening benefits and substantial harms. We summarize the evidence on lead time to the development of invasive cervical cancer, incidence of cervical precancerous lesions and invasive cancer in young women, and harms of screening in young women, which has informed policies to delay the age at which cervical screening begins.Cervical cancer is caused by high-risk human papillomavirus (HPV) infection in susceptible women who do not clear it. Persistent infection may develop into precancer, and for a small proportion of patients, invasive cervical cancer. According to multiple epidemiologic studies, before screening, incidence of cervical cancer among unscreened populations was high from 35 to 65 years, which suggests a long lead-time from initial HPV infection at some time after the onset of sexual activity to the development of invasive cancer. 4,5 There are few studies of the untreated natural history, but a cohort study in New Zealand found that invasive cancer developed in 30% of women with carcinoma in situ (cervical intraepithelial neoplasia 3) over 30 years of follow-up. 6 Invasive cancer of the cervix is uncommon among women under age 25 years, regardless of screening practices. In Canada, the incidence among young women between 15 and 19 years of age has not changed since the era before widespread screening began in 1971: three per million.5 Among women between 20 and 24 years of age, incidence decreased from 3.2 to 1.2 per 100 000, with no change in uncommon mortality from invasive cervical cancer despite programs of annual screening, a pattern that reflects what has been observed in other high-income countries. 5On the other hand, abnormal screening results and precancerous cervical lesions are commonly observed in younger women. Rates of abnormal pap tests among women 20 to 24 years of age vary from 7.3% in British Columbia 7 to 23% in Newfoundland and Labrador.8 Most abnormalities are low grade and represent transient HPV infections that regress without intervention: few progress to high-grade precancer. A study in California involving 95 women under the age of 24 years with a...

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Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis

Cited by 353 publications

References 119 publications

The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women

The Role of PTB Clinics: A Review of the Screening Methods, Interventions and Evidence for Preterm Birth Surveillance Clinics for High-Risk Asymptomatic Women

Using novel biomarkers to triage young adult women with minor cervical lesions: a cost‐effectiveness analysis

Evidence that supports policies to delay cervical screening until after age 25 years

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