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Scaling cervical cancer screening in Mozambique: analysis of loop electrosurgical excision procedure (LEEP) specimens
  1. Sydney Chambule1,
  2. Ricardina Rangeiro2,
  3. Samantha Batman3,
  4. Eva Lathrop4,
  5. Nafissa Osman5,
  6. Andrea Neves6,
  7. Arlete A N Mariano7,
  8. Jean Claude Nkundabatware8,
  9. Carla Carrilho9,
  10. Eliane C S Monteiro10,
  11. Rosita Paulo Mugolo11,
  12. Joseph P Thomas12,
  13. Jennifer Carns13,
  14. Viviane Andrade14,
  15. Hira Atif2,
  16. Ellen Baker3,
  17. Bryan M Fellman15,
  18. Rebecca Richards-Kortum13,
  19. Kathleen M Schmeler3,
  20. Cesaltina Lorenzoni11 and
  21. Mila Pontremoli Salcedo3
    1. 1University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
    2. 2Obstetrics and Gynecology, Hospital Central de Maputo, Maputo, Mozambique
    3. 3Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    4. 4Global Medical Director, Population Services International, Washington, District of Columbia, USA
    5. 5Obstetrics and Gynecology, Universidade Eduardo Mondlane, Maputo, Mozambique
    6. 6Obstetrics and Gynecology, Hospital Geral e Centro de Saúde José Macamo, Maputo, Mozambique
    7. 7Obstetrics and Gynecology, Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
    8. 8Obstetrics and Gynecology, Hospital Provincial de Xai-Xai, Xai-Xai, Mozambique
    9. 9Anatomical Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique
    10. 10Pathology, Hospital Geral e Centro de Saúde de Mavalane, Maputo, Mozambique
    11. 11Pathology, Hospital Central de Maputo, Maputo, Mozambique
    12. 12Department of Oncology Care and Research Information Systems, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    13. 13Bioengineering, Rice University, Houston, Texas, USA
    14. 14Research, ICON Strategic Solutions, São Paulo, Brazil
    15. 15Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    1. Correspondence to Professor Mila Pontremoli Salcedo; Mpsalcedo{at}mdanderson.org

    Abstract

    Objectives As cervical cancer screening programs are implemented and expanded, an increasing number of women require loop electrosurgical excision procedure (LEEP) for treatment of pre-invasive cervical disease. Our objective was to describe the pathological results of LEEP specimens performed as part of the MULHER study and identify factors associated with positive LEEP margins.

    Methods The MULHER study enrolled 9014 women who underwent HPV testing followed by visual assessment for treatment (VAT) using visual inspection with acetic acid (VIA) and thermal ablation for those with positive results. Participants with lesions ineligible for ablation underwent LEEP. Pathology reports were reviewed for specimen size/volume, number of fragments, pathological diagnosis and margin status. Multivariable regression analysis was performed to identify variables associated with positive LEEP margins.

    Results 169 participants underwent LEEP. The median age was 38 years (range 30–49). 65.1% were women living with HIV. Pathological diagnosis was available for 154 patients and included cancer (n=6, 3.9%); cervical intraepithelial neoplasia (CIN) 2/3 (n=75, 48.7%); CIN 1 (n=67, 43.5%); and normal/benign findings (n=6,3.9%). 31.8% of LEEP specimens were removed in more than one fragment. The mean specimen volume was 2.9 cm3 (range 0.2–15.0). LEEP margin status was available for 130 patients. Positive margins (ectocervical/endocervical only, or both) were noted in 76 (58.5%) patients and associated with HIV+status (p=0.0499) and a diagnosis of CIN 2 or worse (p=0.0197). There were no associations between margin status and age, number of fragments or specimen volume.

    Conclusion Our results showed a high number of LEEP specimens with positive margins. Additional evaluation is needed to better understand the characteristics of precancerous cervical lesions in this high-risk population. As cervical cancer screening programs are scaled in Mozambique and other lower-resource countries, there is a need to train providers to perform high-quality LEEP and for accurate and timely pathological interpretation.

    • Cervical Cancer

    Data availability statement

    Data are available upon reasonable request. De-identified datasets, the study protocol, and informed consent form are available upon reasonable request and subject to approval by the ethics committees overseeing the study.

    https://doi.org/10.1136/ijgc-2024-005827

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      Data availability statement

      Data are available upon reasonable request. De-identified datasets, the study protocol, and informed consent form are available upon reasonable request and subject to approval by the ethics committees overseeing the study.

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      Footnotes

      • CL and MPS are joint senior authors.

      • X @kortum, @https://x.com/kmschmeler, @MilaPSalcedo

      • Presented at The preliminary results of this study were presented at the International Gynecologic Cancer Society (IGCS) Annual Global Meeting, Seoul, South Korea, November 2023.

      • Contributors Conception and design: MPS, EL, CL, and KMS. Administrative support: MPS, EB, EL, RR, CL, and KMS. Provision of study material or patients: NMRBO, AFdN, RR, AANM, ECSM, CC, JCN, and CL. Collection and assembly of data: SC, JPT, MPS, VA, HA, BMF, and KMS. Data analysis and interpretation: SC, MPS, VA, BMF, and KMS. Manuscript writing: all authors. All authors had access to all the data, contributed to the interpretation of the data, and revised, edited, and approved the final version of the manuscript before submission. All authors had final responsibility for the decision to submit for publication. Guarantor of the manuscript: KMS.

      • Funding This research was primarily supported by the American people through the United States Agency for International Development (USAID) and was prepared under Cooperative Agreement AID-OAA-A-11-00012, USAID-Partnerships for Enhanced Engagement in Research (PEER) Program/NASEM. Additional support was provided from the United States National Cancer Institute through the MD Anderson Cancer Center Support Grant (P30CA016672) as well as philanthropic funds from the Giles-O’Malley, and Joe families.

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.