Browsing by Author "Adams, Robyn Anne"

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    Exploring options for the secondary prevention of cervical cancer in South Africa
    (Stellenbosch University, 2024-12) Adams, Robyn Anne; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynaecology.
    ENGLISH ABSTRACT: Cervical cancer stands as a significant global health challenge, impacting millions of women annually. While primary prevention measures like human papilloma virus (HPV) vaccination show promise, the role of secondary prevention, including screening programmes and early detection methods, is paramount. This thesis aims to assess and elucidate the multifaceted nature of secondary prevention strategies for cervical cancer. In Chapter 2, the evolution and current state of cervical cytology in South Africa is discussed, highlighting its successes and systemic challenges. The chapter emphasises the need for robust infrastructure, efficient follow-up systems, and the lessons learned from cytology that can inform the implementation of HPV DNA screening. In Chapter 3, the study findings suggest that visual inspection methods perform better in women living with HIV (WLWH) compared to HIV-negative women. This implies the justification for utilizing visual inspection methods in cervical cancer screening for WLWH. However, it is noted that these methods exhibit satisfactory sensitivity only under rigorous quality assurance measures, which might pose challenges in non-academic settings, potentially leading to over-treatment due to reduced specificity. Chapter 4 explores cervical cancer control guidelines in the Southern African Development Community (SADC) region, highlighting the reliance on visual inspection as a screening method, despite the World Health Organization (WHO) prioritizing HPV deoxyribose nucleic acid (DNA) testing in its guideline of 2021. HPV DNA testing offers high sensitivity and a negative predictive value approaching 100%, reducing the need for frequent follow-up visits and additional tests, thus enhancing cost-effectiveness. However, HPV DNA testing alone may not provide clinically relevant information without a triage test to identify women with clinically significant disease. A pragmatic advantage of HPV testing is its compatibility with triage tests like host-cell DNA methylation assessment, streamlining the diagnostic process and reducing discomfort for individuals undergoing screening. In South Africa, HPV testing is increasingly available, with reflex cytology recommended as the triage test, though molecular biomarkers like DNA methylation show promise for further risk stratification. However, more evidence is needed, particularly in low- and middle-income countries (LMICs), to support their inclusion in screening programmes. Chapter 5 discusses the potential of DNA methylation assays as triage tools, citing studies showing high sensitivity for cervical cancer detection. However, conclusive evidence is lacking, especially in LMICs, necessitating further research and adaptation of methylation assays for cost-effective use. Longitudinal studies focusing on women living with HIV are particularly crucial due to limited existing research. Chapter 6 outlines a study protocol comparing thermal ablation (TA) to large loop excision of the transformation zone (LLETZ) in treating cervical precancer, acknowledging South Africa's human immunodeficiency virus (HIV) burden and high-risk HPV prevalence. Understanding TA's efficacy including treatment failure rates is vital for adopting accessible treatments, considering the context of resource constraints. In summary, secondary prevention of cervical cancer involves a diverse array of strategies, from screening methods to treatment modalities. While HPV DNA testing represents a significant advancement, challenges remain in implementation, especially in LMICs. Further research, particularly on triage methods and treatment efficacy, is essential for improving outcomes, especially in populations disproportionately affected by cervical cancer.