ANTICANCER RESEARCH 25: 3469-3480 (2005) Comparing PAP Smear Cytology, Aided Visual Inspection, Screening Colposcopy, Cervicography and HPV Testing as Optional Screening Tools in Latin America. Study Design and Baseline Data of the LAMS Study* K. SYRJÄNEN1, P. NAUD2, S. DERCHAIN3, C. ROTELI-MARTINS4, A. LONGATTO-FILHO5, S.TATTI6, M. BRANCA7, M. ERZEN8, L.S. HAMMES2, J. MATOS2, R. GONTIJO3, L. SARIAN3, J. BRAGANCA3, F.C. ARLINDO4, M.Y.S. MAEDA5, A. LÖRINCZ9, G.B. DORES10, S. COSTA11 and S. SYRJÄNEN12 1Department of Oncology and Radiotherapy, Turku University Central Hospital, Turku, Finland; 2Hospital de Clinicas de Porto Alegre; 3Universidade Estadual de Campinas, Campinas; 4Hospital Leonor M de Barros, Sao Paulo, Brazil; 5Instituto Adolfo Lutz, Sao Paulo, Brazil and University of Minho, Braga, Portugal; 6First Chair, Gynecology Hospital de Clinicas, Buenos Aires, Argentina; 7Unit of Cytopathology, National Centre of Epidemiology, Surveillance and Promotion of Health, National Institute of Health (ISS), Rome, Italy; 8SIZE Diagnostic Center, Ljubljana, Slovenia; 9Digene Corp., Maryland, U.S.A.; 10Digene Brazil, Sao Paulo, Brazil; 11Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, Bologna, Italy; 12Department of Oral Pathology, Institute of Dentistry, University of Turku, Finland Abstract. Objectives: This is a European Commission (EC)- positive in any test and for 5% of women with baseline PAP- funded ongoing study known as the LAMS (Latin American negative and 20% of HCII-negatives. All high-grade lesions Screening) study, where PAP smear/liquid-based cytology and (CIN2/3) were treated, and low-grade CIN are prospectively screening colposcopy were compared with i) three optional followed-up. Results: Of the 12,107 women, the following screening tools [visual inspection with acetic acid (VIA), or baseline data are available: epidemiological data (n=11,996), Lugol’s iodine (VILI), cervicography] and with ii) Hybrid conventional PAP smears (n=10,363), LBC, SurePATH Capture II from a) conventional samples and from b) self- (n=320), LBC, DNA-Citoliq (n=1,346), VIA (n=12.067), samples, in women at different risk for cervical cancer in Brazil VILI (n=3,061), cervicography (n=279), screening colposcopy and Argentina. Study Design: During 2002-2003, a cohort of (n=3,437), HCII conventional (n=4,710), HCII self-sampling 12,107 women attending four clinics: Campinas (CA), Sao (n=246) and cervical biopsies (n=1,524). The four sub- Paulo (SP), Porto Alegre (PA) and Buenos Aires (BA), were cohorts differ significantly in all their baseline data on the interviewed for risk factors, and examined using the 8 implicated risk factors of cervical cancer, consonant with their diagnostic arms. Colposcopy was performed for women origin from regions with different cancer incidence. Around 95% of all PAP smears were negative, with slight variations in the prevalence of LSIL and HSIL between the four centers. Significant differences were found in the detection rates of *LAMS: Latin American Screening Study, funded by the European abnormal findings in VIA, VILI and colposcopy between the Commission, INCO-DEV Contract # ICA4-CT-2001-10013 four centers (p=0.0001). The prevalence of HPV was practically identical (16.5-18.8%) in all four cohorts Correspondence to: Prof. Kari Syrjänen, MD, Ph.D., FIAC. SMW (p=0.486), with no differences in the relative viral loads. Consultants Ltd., Kylliäisentie 9, FIN-21620 Kuusisto, Finland. Biopsy results were different depending on whether the women Tel: +358-2-2557145, Fax: +358-2-2557178, e-mail: kari.syrjanen@ smwconsultants.fi underwent screening colposcopy (BA) or elective colposcopy (others). Conclusion: Four cohorts with significantly different Key Words: Screening, HPV, HPV testing, colposcopy, liquid-based baseline data are available, and prospective follow-up of these cytology, cervicography. women permits analysis of whether variations in cervical 0250-7005/2005 $2.00+.40 3469 ANTICANCER RESEARCH 25: 3469-3480 (2005) Figure 1. Flowchart of patient examination, treatment and follow-up. cancer incidence in these regions is due to i) different natural solutions to cope with this increasing problem (5-8, 10, 13). history of the precursor lesions, or ii) due to different levels of A variety of optional screening tools have been introduced exposure to the known risk factors. to be used in conjunction with, or independently of, the PAP test (7, 8, 10, 12, 13). These include: visual inspection Cervical cancer has an uneven geographic distribution, with with acetic acid (VIA) or Lugol’s iodine (VILI), the vast majority of cases being confined to regions where cervicography, speculoscopy, colposcopy, liquid-based- and the resources to combat the disease are the most meager, automated cytology, all under rigorous testing in different i.e., in developing countries (1-4). There is no argument that settings (7, 8, 10, 12-18). the declining trends in incidence and mortality rates Testing for Human papillomavirus (HPV) by different witnessed in developed countries over the past four decades molecular tools (Hybrid Capture, PCR) has been proposed are mainly attributable to the implementation of organized as an adjunct or independent screening tool, with several screening programs based on the cervical Pap smear (5-8). potential advantages (3, 7, 8, 12, 17, 19-24). Testing for the The best examples are the Nordic Countries, where etiological agent of cervical cancer (3, 4, 19, 25-27) offers organized screening has resulted in up to an 80% reduction an opportunity to detect the women at increased risk of in cervical cancer incidence since the early 1960’s (7-12). cervical cancer at the stage of latent and subclinical HPV Unfortunately, these highly effective organized screening infection, preceding (by several months to years) the clinical programs exist only in a few countries, and the prospects for stages (SIL, CIN) detectable by the PAP test, which makes effective PAP smear screening in the majority of the cervical cancer unique among all human malignancies (3, 4, developing countries seem gloomy, if not entirely 7, 8, 12, 13, 19 ,24 ,25, 28, 29). pessimistic, in the foreseeable future (7, 8, 10, 12, 13). This On the global scale, the countries of Latin America are fact has been well recognized among the scientific among those with the highest incidence and mortality rates community, emphasizing the necessity to find other of cervical cancer (1, 2, 7, 8, 10). Despite some local efforts 3470 Syrjänen et al: Testing Optional Screening Tools in Latin America to establish cervical cancer screening, no organised national Second visit. Women testing positive with any of these screening programs exist in any of these countries, techniques were examined by colposcopy at the second visit. The including Brazil and Argentina (7, 8, 17, 23, 30). Thus, cytology cut-off for referral included women with ASC-US, "abnormal" being the referral cut-off for VIA, VILI, cervicography there is no demonstrable trend to decrease the cancer and screening colposcopy. In addition, a 5% random sample of all morbidity in these two countries (1, 2, 30). These test-negative (PAP, VIA, VILI) women will be submitted to conditions prompted us to design the present study to test colposcopy, as will be 20% of those testing negative with HCII (at eight different screening tools in a large cohort of women 24 months), to assess the incidence rates of PAP smear enrolled in four clinics in regions with different incidences abnormalities and HPV infections. When subjected to colposcopy, of cervical cancer (30, 31). these baseline negative women will contribute to correction of the This multi-center trial has two main aims: i) to evaluate verification bias, otherwise inevitable in this type of study design, where only a minority of the patients are verified by the gold the feasibility of eight different diagnostic tests as screening standard (=colposcopic biopsy). tools in these settings, and ii) to test the hypothesis that the On colposcopy, all abnormal findings were confirmed by different incidence of cervical cancer in these regions directed punch biopsies. The result of the punch biopsy was used as depends on a) the different clinical course of cancer the gold standard for the cervical pathology, against which all the precursors, or b) on the different exposure of these women other diagnostic tests will be compared while calculating their to the known risk factors, e.g. HPV. The former is necessary performance (sensitivity, specificity, negative- and positive- to find out the cost-effective tools for cervical cancer predictive values). The women with biopsy-confirmed low-grade screening in these low-resource settings, while the latter CIN (HPV– or HPV+) comprise the cohort to be prospectively followed-up for a minimum of 24 months, to elucidate the disease offers the possibility of further elucidating the natural outcome. All high-grade lesions were promptly treated and history of cervical cancer and its precursors in women at followed-up for the same period, using repeated PAP test, VIA and different risk for cancer. HCII assay at 6-month intervals, and were subsequently The present communication describes the study design colposcopied if any of these tests were positive. and the baseline data of this multi-center trial, known as the Latin American Screening study (the LAMS study). Patients. In the first phase, the four clinics examined a total of 12,107 women, between February 2002 and June 2003, comprising Patients and Methods the LAMS Study cohort, from which all the baseline data are derived. The mean age of the women was 37.9 years (range 14-67; General study design. The ongoing LAMS (Latin American Median 37.7 yrs). Altogether, 74% of the women were Caucasian, Screening) study is a multi-center screening trial targeted at female 9% were colored, 16% mixed, and less than 1% of other origin. populations at different risk for cervical cancer in two Latin The key clinical characteristics and epidemiological data recorded American countries, Brazil and Argentina (32).