A Dutch study suggests that extending intervals for human papillomavirus (HPV) testing beyond 5 years—with risk stratification—may be appropriate in some women. Published in BMJ, the findings are from the POBASCAM trial, which reflected 14 years of follow up on HPV- and/or cytology-negative participants.
The randomized cohort included 43,339 women aged 29 to 61 who were randomly assigned to HPV and cytology co-testing (intervention) or cytology testing alone (control). The women underwent cervical cancer screening once every 5 years for 3 rounds and were managed based on the test results.
In the Netherlands, cytological-based cervical cancer screening is offered free to women aged 30 to 60 at 5-year intervals. Beginning in 2017, the interval will be extended to 10 years for HPV-negative women aged ≥40. Under the current program, the documented cumulative 5-year risk of cervical intraepithelial neoplasia (CIN) 3+ after a negative screen is <1%. In other countries, such as Australia, Italy, New Zealand, and UK, women are screened every 2 to 3 years and there the interval is being expanded to 5 or 7 years.
The Dutch investigators looked at cumulative incidence of cervical cancer and CIN grade 3 or worse (CIN3+) and estimated in HPV-positive women reductions in CIN3+ incidence after negative cytology, HPV type 16/18 genotyping, and/or repeat cytology. They found that the cumulative incidence of CIN3+ among HPV-negative women was similar to that in women with negative cytology who had undergone 2 rounds of screening (0.09% and 0.69%, respectively). Cervical cancer and CIN3+ risk ratios were 0.97 (95% confidence interval [CI] 0.41 to 2.31, P=0.95) and 0.62 to 1.09, P=0.17) in the two groups, respectively.
In HPV-negative women aged ≥40, compared with younger women, CIN3+ incidence was 72.2% lower (95% CI 61.6% to 79.9%, P<0.01). There was no significant association between cervical cancer incidence and age. In HPV-positive women with negative cytology, HPV 16/18 genotyping, and/or repeat cytology, CIN3+ incidence was 10.4 times higher than among HPV-negative women (95% CI 5.9 to 18.4).
The authors concluded that the low long-term incidences of cervical cancer and CIN3+ among HPV-negative women who were studied support extension of the cervical cancer screening interval beyond 5 years in women aged ≥40. Risk stratification should be incorporated into HPV-based programs with intervals >5 years, they said, because of the finding that risk of CIN3+ is at least fivefold higher in HPV-positive women with subsequent negative cytology HPV16/18 genotyping, and/or repeat cytology than in HPV-negative women.
How azithromycin prophylaxis before cesarean can reduce postop infection
A multicenter study funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and published in the New England Journal of Medicine may indicate that the addition of azithromycin prophylaxis before cesarean delivery could prevent postoperative infection.
The study was conducted in 14 centers across the United States. The researchers looked at 2013 women who had a singleton pregnancy with gestation lasting 24 weeks or more and were undergoing cesarean delivery during labor or after membrane rupture. They assigned 1019 of the women to received 500 mg intravenous azithromycin and 994 to receive placebo. Each woman was scheduled to receive the standard antibiotic prophylaxis. Primary outcome was a composite of wound infection, endometritis, or other infection occurring within 6 weeks.
Primary outcome occurred in 62 women (6.1%) who had received azithromycin and in 119 (12.0%) who had received the placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). Significant differences were observed between the azithromycin group and the placebo group in rates of endometritis (3.8% vs 6.1%, P=0.02), wound infection (2.4% vs 6.6%, P<0.001), and serious maternal adverse events (1.5% vs 2.9%, P=0.03). When looking at secondary neonatal composite outcomes, such as neonatal death or serious neonatal complications, no significant between-group differences were seen (14.3% vs 13.6%, P=0.63).
The researchers concluded that adjunctive azithromycin along with standard antibiotic prophylaxis were more effective than placebo in reducing the risk of postoperative infection.