To explore the barriers to successful home-based human papillomavirus (HPV) self-sampling in North Gondar, Ethiopia.The study participants were women who had previously participated in a community-wide home-based HPV self-sampling pilot study, community health workers, women’s development army leaders, and the sample collectors of the home-based HPV self-sampling pilot study. A community based qualitative descriptive study was conducted. We applied purposive and convenience sampling. In total, 47 women participated in the study . The study employed thematic analysis for clustering the emerged themes.Husband disapproval was identified as the main barrier to the acceptance of home-based HPV self-sampling. Social influence, lack of knowledge about cervical cancer and screening, lack of health education on cervical cancer and HPV-based screening, feeling healthy, and religious influence were identified as additional barriers. Fear of using Evalyn brush® for self-sampling was found to be the main barrier to the provision of a quality sample. The inability of the sample collectors to check the proper utilization of Evalyn brush® and the difficulty in understanding the instructions did also contribute to the low-quality. Providing health education concerning cervical cancer and HPV self-sapling to women, male involvement in the screening program, and linking the screening service to existing local health facilities were suggested to guarantee the success of home-based HPV self-sampling.Educating women regarding cervical cancer and HPV testing, providing clear instructions on how to collect self-sample, and male involvement in the screening program are prerequisites for a successful implementation of home-based HPV testing. Women empowerment should also be focused to overcome the identified sociocultural barriers. Furthermore, the screening program should guarantee the timely provision of the test results and offering women follow-up examinations and treatment for abnormal findings. Cervical cancer ranks as the fourth most commonly diagnosed and cause of cancer death among women globally . This diIn contrast to high-income countries where population-based vaccination, organized cytology-based screening, and treatment programs have successfully reduced cervical cancer incidence and mortality, the burden has remained unchanged in low- and middle-income countries (LMICs) due to poor health care services –8.The World Health Organization (WHO) recommends the use of either visual inspection with acetic acid (VIA) or HPV test strategies for cervical cancer screening (CCS) in LMICs, since cytology-based screening requires too many resources . HPV-basThe identified drivers of HPV self-sampling cost-effectiveness include the level of increase in cervical cancer screening attendance, lower HPV self-sampling materials and testing costs, and attracting under-screened women –21. AddiAs part of the implementation of the national cancer control strategy in 2015, the Ethiopian Federal Ministry of Health (FMoH) introduced HPV vaccination for 14-years-old girls in 2018 and has planned to provide vaccination for girls of 9–14 years through the routine immunization program , 29. BesSeveral barriers limit the acceptance and success of CCS in LMICs, including limited knowledge of cervical cancer, lack of awareness about screening methods, misconceptions about causes, ignorance of prevention methods, spousal disapproval, misbelief of not being at risk, fear of self-harm and contravening religious and/or cultural obligations of modesty during the screening procedure –34.In order to increase CCS coverage in Ethiopia, a community-wide pilot study was conducted in Dabat district, North Gondar in 2017, utilizing a home-based HPV self-sampling approach. Women aged 25–65 years were offered Evalyn brush® for HPV self-sampling in their homes. The findings of this study showed that the acceptance rate for the HPV self-sampling was 85%. Although the study management followed strictly international guidelines and procedures to assure the quality of samples, about one-fifth of the samples were insufficient for HPV testing . HoweverPrior to the pilot study, a first qualitative study was conducted in a similar setting that identified the perceptions, acceptability, barriers, and preferences for HPV self-sampling in focus group discussions (FGDs) . ComplemUniversity of Gondar referral hospital is the only tertiary hospital in the North Gondar Zone, providing services for about 5 million population; it has been providing CCS via VIA and cryotherapy services since 2013 . Chila KA qualitative study design was used to explore the barriers to successful home-based HPV self-sampling, using in-depth interviews (IDIs) and FGDs. We conducted IDIs to explore participants' knowledge, perceptions, beliefs, and experiences on barriers to acceptance of home-based HPV self-sampling and to the provision of a sufficient quality HPV testing sample as explained in the literature –45. AddiStudy participants were women who had participated in a community-wide home-based HPV self-sampling, CHWs, WDALs, and the sample collectors of the pilot study. All IDIs and two FGDs were conducted with women who participated in home-based HPV self-sampling pilot study. Additionally, one FGD targeted the HPV sample collectors to grasp their experiences with instructing the women on the self-sampling instrument , and another FGD was conducted with CHWs and WDALs, considering their in-depth understanding of the cultural context and the community’s health-seeking behaviour , 48.A purposive sampling technique was used to select the women, based on HPV testing sample quality criteria. CHWs, WDALs, and the sample collectors were selected by convenience sampling based on their working schedule, distance from FGD site, and availability to participate . Each ofSemi-structured interview guides were developed for both IDIs and FGDs in English and then translated to Amharic. The questions were prepared by the study management of the pilot study, taking into consideration the literature on CCS in Ethiopia , 51, 52.The IDI guide was pretested on five women, whereas the FGD guide was pretested on a group of four. Afterwards, the interview guides were adjusted accordingly. The interview guide for the FDG with the HPV sample collectors was checked by the Dabat research site coordinator. None of the women who participated in the pretest were included in the actual data collection.Data collection was done within two weeks in June 2019. In light of the sensitive issue, the IDIs and FGDs were carried out by three female qualitative data collectors, experienced as data collectors in the community (Dabat research center) and in the pilot study. Yet, the FGD with the HPV testing sample collectors was facilitated by the principal investigator at the Dabat health center. The other FGDs were conducted at a health post in Chila kebele and the IDIs took place at the respondents’ households in a confidential setting. A tape-recorder was used to capture all data from the IDIs and the FGDs. Additionally, field notes were taken for all FGDs to capture the main themes of the discussion.The main points of IDI discussions were knowledge, perceptions, and beliefs on cervical cancer and screening, the barriers to acceptance of home-based HPV self-sampling and to provide a sufficient quality HPV testing sample. In contrast, the FGDs discussions focused on the knowledge, perceptions, and beliefs on cervical cancer and screening. The sample collector’s discussion guide focused on the barriers to acceptance of home-based HPV self-sampling in the society and the provision of a sufficient quality HPV testing sample see .The audio-recorded data were transcribed into Amharic. Then, the consistency of the transcription was checked by randomly choosing parts of the recorded data and crosschecking with the transcription. Thereafter, the transcriptions were translated into English and coded into main themes using NVivo (version 12). We employed thematic analysis for identification of the four main themes, based on the participants' experience and opinions , 57: i) Ethical approval for the study was obtained from the Ethics Committee of Heidelberg University School of Medicine, Germany, ethical approval number: S-132/2019 and the Institutional Review Board of the University of Gondar, Ethiopia, ethical approval number: V/P/RCS/05/2032/2019. The information sheet was explained verbally to the participants until they have completely understood it. Information concerning the objectives of the study, voluntary participation, and the right to withdraw from participation at any point of the study, handling of personalized data, possible risk and benefits of the participation in the study was given to the participants. After the participant’s questions were addressed and they confirmed the information they received was clear, written consent was obtained from all the study participants.Data were collected from a total of 47 participants (25 (53%) participated in FGDs, 22 (47%) in IDIs). The average age was 36 years. The majority of the participants were married (83%) and had no formal education (45%). The average family had 4 children .Nekersa (cancer) in the community, but some of the participants understood cervical cancer as haemorrhoids (Kintarot), uterine prolapse, and fistula. Some of the participants indicated that they had heard about cervical cancer for the first time when the pilot study was implemented. However, some of pilot study’s participants acknowledged that they did not know about cervical cancer despite their participation in HPV self-sampling , sudden exposure of the body to sunlight (Mitat), smoke from open fire cooking (Tis) and home delivery as the primary causes of cervical cancer   see .The participants shared the common perception that every woman is at risk of cervical cancer and they related their susceptibility to the reasons they mentioned as the causes of the disease see  quote 5.The majority had recognized the benefits of their participation in HPV self-sampling see . The mosSome participants of IDIs and the sample collectors highlighted that health education was not properly provided prior to the implementation of the pilot study, most importantly on how to properly use Evalyn brush®  should be available at nearest health facility  and used for frequent health education e.g., during family planning education so that women could avoid the fear of using it.Furthermore, community-based HPV testing should engage women, women’s health development army leaders, community leaders, religious leaders, community health workers, and husbands in the screening program to effectively address the low cervical cancer screening in the study area. It is also very important to provide the test results on time and to offer follow-up and treatment for women with abnormal findings. Finally, future randomized studies could test certain measures, for instance, the participatory development and application of appropriate teaching materials.S1 File(PDF)Click here for additional data file. 11 Jun 2020PONE-D-20-06352Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study.PLOS ONEDear Dr. Megersa,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.Please submit your revised manuscript by Jul 25 2020 11:59PM. 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Reviewer #1: Review PLOS ONE - PONE-D-20-06352Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study.This is a collaborative study between research groups in Ethiopia and Germany to assess the barriers to carrying out self-sampling of the vaginal canal at home to identify HPV as a cervical cancer screening strategy.The main findings can be attributed ot sociocultural factors and indicate that the main barriers are the husband’s attitude, the social environment, lack of knowledge of cervical cancer and its etiology; and to absence of recommendation and acceptance of this practice by health workers as a whole and by localo community leaders.The manuscript as such is a pilot study that uses a methodological strategy of in-depth interviews with 22 women and the development of 4 focus groups of 6-7 women each. It is widely described although the information is not very original and recommendations are few.The information obtained is, again, not original. The results obtained are similar to those reported in the 1980s on barriers to the use of cervical cytology in poor countries, as well as on the acceptability of HPV testing and vaginal canal autotomy since the late 1990s.Concern for the correct use of vaginal auto-collection instruments and the feeling of shame with male partners and health professionals is a fact of life in most cultures. The manuscript is generally very descriptive, with very limited recommendations for the context of a geographic area of very low cervical cancer screening coverage. Although the manuscript was written to describe barriers to utilization, it would have been advisable to list possible interventions to improve acceptability and how to address low healthcare coverage in population-based screeReviewer #2: Dear Authors, thank you for the opportunity to review your manuscript entitled “Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study”. This is a niece piece of work aimed at understanding women’s experience and perspectives about HPV self-sampling for cervical cancer screening following a pilot study in Ethiopia, Eastern Africa.This paper could be improved by addressing the following concerns.The abstract is not very well structured. For instance, the methods should start by describing the study population, then elaborate on the study type and design, before talking about the sampling approach. Also, the conclusion that “HPV self-sampling seems to be a promising strategy to increase low cervical cancer screening coverage in Ethiopia”, does not appear to be related to the study aims and findings.In the data availability section of the manuscript, it says that some restrictions to data access may apply. Please could authors clarify why their data cannot be made publicly available?The first paragraph of the introduction section of the manuscript is a bit confusing. On page 3 lines 42 to 43, it writes: “Cervical cancer ranks second among women aged 15+ years (3), whereas it is the most common cause of cancer in North Western Ethiopia (4)”. Do the authors refer to cervical cancer in terms of incidence, prevalence or mortality? What is the denominator for this comparison? Why would they compare women aged 15 years or older , with women (not sure what is the age range here) in North Western Ethiopia?On page 3 lines 52 to 55, it writes: “HPV-based screening is considered to be cost-effective and to be the most suitable strategy to increase the coverage of CCS in a resource-poor setting due to better accessibility and enabling women to take a self-collected cervicovaginal sample at home .” Do authors mean that HPV is more available than VIA in limited resource settings? Do they mean that self-collection is more valuable when performed at home? Are the reasons highlighted in this sentence the main reasons why HPV screening is the most cost-effective strategy for CCS in limited resource settings? Please, clarify.On the other hand, many references used throughout the manuscript are not up-to-date. For instance, the current reference (6), could be replaced by more recent and more adapted reference,s such as the following: Fokom Domgue J & Valea F, 2018. Is it relevant to keep advocating VIA for cervical cancer screening in limited resource settings? Journal of Global Oncology, 2018; or Defo VF et al, 2020. Why consider self-sampling for cervical cancer screening in limited resource settings? AMA Journal of Ethics, 2020.On page 4 lines 76 and 77, it writes: “Insufficient samples were provided in about one-fifth of the cases )”. This fact that HPV specimens and results were invalid or insufficient in about 20% of specimens, is not necessarily due to the poor quality of self-samples provided by women, but could be due to many factors related to the storage, transportation and processing of these specimens, the delay between self-sampling and HPV testing, inter alia. Please clarify. On the other hand, a 82.5% acceptance rate in a pilot study does not seem low to me, and the when comparing this rate to the existing literature, the authors should ensure that the study population in previous reports is comparable to theirs.In the methods section, the main concern is related to the interval (about 2 years) between the implementation of pilot study (2017) and the conduct of the follow-up study presented in this manuscript (2019). Why did the authors wait for so long before surveying participants  after they were exposed to self-sampling? How did they ensure that the responses provided in 2019 about an experience they had in 2017 was accurate?On the other hand, participants were classified according to whether their samples were sufficient or insufficient. As mentioned above, a sample classified as insufficient could be due to many factors other than the ability of women to properly perform self-sampling.Further, the authors should check and correct grammatical and typo- errors that are found throughout the manuscript.Once these points have been addressed, the results and the discussion can be updated accordingly.Thank you.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool, AttachmentReview Community cervical cancer screening PLOS ONE1 (2).docxSubmitted filename: Click here for additional data file. 15 Sep 2020Rebuttal letter for Reviewers comment PONE-D-20-06352Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study.We thank the reviewers for the helpful comments. The changes made and our responses to the mentioned points are as follows:Reviewer one Comment: It is widely described although the information is not very original, and recommendations are few. The results obtained are similar to those reported in the 1980s on barriers to the use of cervical cytology in poor countries, as well as on the acceptability of HPV testing and vaginal canal autotomy since the late 1990s.Answer: In comparison to other studies, our study identified somewhat the real barriers to HPV self-sampling in the study area since the study conducted following the conduct of the preliminary community-wide home-based self-sampling. Yet, as commented by the reviewer, some of the findings of this study are similar to the findings of other studies conducted elsewhere to assess the acceptance of HPV self-sampling. However, some of the findings are rarely reported in other studies. For instance, husband and neighbour disapproval, religious influence as a barrier to the acceptance of HPV self-sampling, and some of the misconceptions about cervical cancer and screening identified in this study have been rarely reported in other HPV self-sampling studies. This study also identified some of the implementation limitations such as the inability of the sample collectors to check the proper utilization of self-sampling kit  , delay in providing test results, and follow-up and treatment for women with abnormal findings which are rarely reported in other studies . Moreover, this study provided a clue on how it was difficult to understand the instruction of self-sampling for rural women which is rarely identified in other studies. Furthermore, the results of the study were used to develop a conceptual model to explain determinants for the success of HPV self-sampling which we did not come across in other studies . Thus, although our study shares some of the findings with other studies, still some of the findings are rarely reported. Comment: Concern for the correct use of vaginal auto-collection instruments and the feeling of shame with male partners and health professionals is a fact of life in most cultures. The manuscript is generally very descriptive, with very limited recommendations for the context of a geographic area of very low cervical cancer screening coverage.Answer: As the reviewer has indicated, several studies have reported the concern of women’s ability to perform self-sampling correctly. However, our study did not identify women’s concern to perform the self-sampling correctly as a barrier, rather we identified that some of the women were afraid the instrument and thought it could hurt their genitalia during self-sampling . Also, the woman’s feelings of shame with her husband/partner to attend cervical cancer screening service and to receive the service from health professionals have been widely reported from provider dependent, clinic settings where it involves pelvic examination. However, our study identified husband disapproval as the main barrier to acceptance of self-sampling. Regarding the recommendations to the study area, previously, we have listed some of the possible recommendations that could improve the acceptance and overall implementation of HPV self-sampling in the study area in the discussion and mainly under conclusion sections. In addition to the previous recommendations, we have added other recommendations in the conclusion part which could improve the acceptance of HPV self-sampling and the implementation of the screening program and consequently could rise the screening coverage in the study area. For example, we included women empowerment, increasing women’s familiarity with the self-sampling kit, and engaging all stalk holders in the screening program to tackle some of the identified socio-cultural barriers . Comment: Although the manuscript was written to describe barriers to utilization, it would have been advisable to list possible interventions to improve acceptability and how to address low healthcare coverage in population-based screening. Answer: As explained above, in addition to recommendations that have been provided, based on the comment, we have added other recommendations in the conclusion section that could help to improve the acceptance of HPV self-sampling and could help to overcome the low cervical cancer screening coverage in the study area . Reviewer twoComment: The abstract is not very well structured. For instance, the methods should start by describing the study population, then elaborate on the study type and design, before talking about the sampling approach. Also, the conclusion that “HPV self-sampling seems to be a promising strategy to increase low cervical cancer screening coverage in Ethiopia”, does not appear to be related to the study aims and findings.Answer: We have re-structured the abstract as commented by first describing the study population, study type and design, and thereafter continued with sampling technique. As the reviewer commented, the sentence “HPV self-sampling seems to be a promising strategy to increase low cervical cancer screening coverage in Ethiopia” in the conclusion part is not supported by the findings of the study and we have omitted the sentence. Comment: In the data availability section of the manuscript, it says that some restrictions to data access may apply. Please could authors clarify why their data cannot be made publicly available?Answer: We have provided in-depth interviews and FGDs guides with quotations from IDIs and FGDs by themes in anonymized form as a supplementary file .Comment: The first paragraph of the introduction section of the manuscript is a bit confusing. On page 3 lines 42 to 43, it writes: “Cervical cancer ranks second among women aged 15+ years (3), whereas it is the most common cause of cancer in North Western Ethiopia (4)”. Do the authors refer to cervical cancer in terms of incidence, prevalence or mortality? What is the denominator for this comparison? Why would they compare women aged 15 years or older , with women (not sure what is the age range here) in North Western Ethiopia? Answer: It was the incidence of cervical cancer that ranks the second most common female cancer in Ethiopia. The reference [3] in the last version has reported the crude incidence of cervical cancer among the adult population of women, 15 years and above based on national cancer data registry, and the denominator was 100,000 population. However, the study that was conducted in Northwestern Ethiopia, reference [4] in the last version was a merely descriptive study reporting the pattern of all cancers by frequency and percentage from a cancer registry of a given hospital. Thus, we have removed it from the list citation. To avoid confusion, we omitted the sentence and replaced it with a clearer sentence “Cervical cancer ranks as the second leading female cancer for both incidence and mortality in Ethiopia .” and we have cited the updated version of the Ethiopian human papillomavirus and related diseases report.Comment: On page 3 lines 52 to 55, it writes: “HPV-based screening is considered to be cost-effective and to be the most suitable strategy to increase the coverage of CCS in a resource-poor setting due to better accessibility and enabling women to take a self-collected cervicovaginal sample at home .” Do authors mean that HPV is more available than VIA in limited resource settings? Do they mean that self-collection is more valuable when performed at home? Are the reasons highlighted in this sentence the main reasons why HPV screening is the most cost-effective strategy for CCS in limited resource settings? Please, clarify.https://www.ncbi.nlm.nih.gov/pubmed/25642554). In addition, the WHO expert panel recommends the use of VIA instead of HPV in resource constrained settings where HPV testing is not available (http://dx.doi.org/10.1016/j.ijgo.2015.07.038). Thus, we have revised the sentence to make it clear. “HPV-based screening is considered to be the most suitable strategy to increase the coverage of CCS in low-resource settings by enabling women to take a self-collected cervicovaginal sample for HPV testing at home.”Answer: “Do authors mean that HPV is more available than VIA in limited resource settings?” We do not mean that HPV is more available than VIA in resource limited setting. Although the WHO guideline recommends the use of either HPV testing or VIA for cervical cancer screening in LMICs, it indicates that VIA is more available for cervical screening than HPV testing in resource limited settings . We have separated the sentence describing the cost-effective of HPV self-sampling and added new citations. “Also, studies conducted in low-income settings have shown that population based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be cost-effective screening strategy.”  “Are the reasons highlighted in this sentence the main reasons why HPV screening is the most cost-effective strategy for CCS in limited-resource settings? Please, clarify.” We have stated the cost-effectiveness of HPV testing based on some studies which were included in the list of the references . Some studies conducted in low- and middle-income countries have indicated that community-based self-collected HPV testing followed by treatment for HPV-positive women has the potential to be a cost-effective screening strategy (doi:10.1136/bmjopen-2017-020484).7). This is true particularly at high coverage levels and when self-collection is associated with greater coverage of screening-eligible women than provider-collection (doi:10.1093/heapol/czw182). In addition, a systematic review has shown that HPV self-sampling could be a cost-effective strategy in LMICs , could be replaced by more recent and more adapted reference,s such as the following: Fokom Domgue J & Valea F, 2018. Is it relevant to keep advocating VIA for cervical cancer screening in limited resource settings? Journal of Global Oncology, 2018; or Defo VF et al, 2020. Why consider self-sampling for cervical cancer screening in limited resource settings? AMA Journal of Ethics, 2020.Answer: Based on the comment, we have updated some of the references and cited the suggested references. Comment: On page 4 lines 76 and 77, it writes: “Insufficient samples were provided in about one-fifth of the cases )”. This fact that HPV specimens and results were invalid or insufficient in about 20% of specimens, is not necessarily due to the poor quality of self-samples provided by women, but could be due to many factors related to the storage, transportation and processing of these specimens, the delay between self-sampling and HPV testing, inter alia. Please clarify. On the other hand, a 82.5% acceptance rate in a pilot study does not seem low to me, and the when comparing this rate to the existing literature, the authors should ensure that the study population in previous reports is comparable to theirs.https://doi.org/10.1016/j.pvr.2020.100198. First of all, each woman was told to use the Evalyn brush®, close it, and give back to the sample collectors immediately, then the sample was stored properly and transported to the storage site. The Evalyn brush™ sample was stored at room temperature (circa 25 °C) for a maximum of 8 weeks (https://doi.org/10.1016/j.pvr.2018.04.005) until processing and analysis. As it has been cited elsewhere, the samples were analyzed using the AID HPV-DNA array test  . Quality control was done at the laboratory of the Clinic for Gynecology, Charité Universitätsmedizin Berlin, Germany using BSGP5+/6+ PCR followed by Luminex-MPG read-out (https://doi.org/10.1002/jmv.25583).Answer: As the reviewer commented, the insufficiency of the samples provided may not necessarily be confined to the inability of the women to collect sufficient self-sample. Additionally, other issues such as storage and transportation have partially could contribute to low quality samples. This, however, is unlikely since the study management followed strictly international guidelines and procedures to assure the quality of the collected samples http://dx.doi.org/10.4314/ahs.v15i3.8). Also, in some of the literature samples which were not adequate returned to each woman and become satisfactory for HPV testing. As such, after following the required procedures to assure the quality of the collected data, the adequacy of the sample for the HPV testing could merely be attributed to the quality of the self-sample collected from women. Similarly, several studies attributed the adequacy of the self-sample for HPV testing to the ability of the women to perform self-sampling  between the implementation of pilot study (2017) and the conduct of the follow-up study presented in this manuscript (2019). Why did the authors wait for so long before surveying participants  after they were exposed to self-sampling? How did they ensure that the responses provided in 2019 about an experience they had in 2017 was accurate?Answer: The interval between the preliminary study and the current is attributed to the following reasons: First of all, the community based preliminary study was conducted in November 2017. The collected samples were sent for HPV testing to Germany and the sampling results were out in June 2018. Thereafter, the inception of the current proposal was proposed in November 2018. The proposal was developed over a period of 4 months and thereafter obtaining ethical clearance from the Heidelberg University and the University of Gondar took about 3 months. Thus, because of the above-mentioned reasons, the survey of CHWs, sample collectors, and women participated in self-sampling was conducted in 2019. https://www.ncbi.nlm.nih.gov/books/NBK539386/. In addition, the sample collectors had demonstrated the procedure of self-sampling to the participants which could help them to memorize the procedure and report their experiences. During the interview, women were also asked whether they remember the procedure of self-sampling, and the majority of those participated in the self-sampling were able to explain the procedure correctly. Regarding the accuracy of the experiences of the participants on self-sampling, studies have demonstrated that recall of cervical cancer screening event is pretty accurate. A study has shown that 96% of cervical cancer screened patients according to their medical record accurately reported their screening Comment: On the other hand, participants were classified according to whether their samples were sufficient or insufficient. As mentioned above, a sample classified as insufficient could be due to many factors other than the ability of women to properly perform self-sampling.https://doi.org/10.1016/j.pvr.2020.100198. Thus, the adequacy of the samples for the HPV testing could merely be attributed to the quality of the self-sample each woman provided. Answer: As described above the study management had taken internationally recognized procedures to assure the quality of the samples during collection, storage, transportation, and analysis Comment: Further, the authors should check and correct grammatical and typo- errors that are found throughout the manuscript.Answer: We have checked and corrected grammatical and typo- errors.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 16 Nov 2020Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study.PONE-D-20-06352R1Dear Dr. Megersa,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Eduardo Lazcano-PonceGuest EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 3 Dec 2020PONE-D-20-06352R1 Community cervical cancer screening: Barriers to successful home-based HPV self-sampling in Dabat district, North Gondar, Ethiopia. A qualitative study. Dear Dr. Megersa:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Eduardo Lazcano-Ponce Guest EditorPLOS ONE


This paper summarises the position of ESGO and EFC on cervical screening based on existing guidelines and opinions of a team of lead experts. HPV test is replacing cytology as this offers greater protection against cervical cancer and allows longer screening intervals. Only a dozen of HPV tests are considered as clinically validated for screening. The lower specificity of HPV test dictates the use of triage tests that can select women for colposcopy. Reflex cytology is currently the only well validated triage test; HPV genotyping and p16 immunostaining may be used in the future, although methylation assays and viral load also look promising. A summary of quality assurance benchmarks is provided, and the importance to audit the screening histories of women who developed cancer is noted as a key objective. HPV-based screening is more cost-effective than cytology or cotesting. HPV-based screening should continue in the post-vaccination era. Only a fraction of the female population is vaccinated, and this varies across countries. A major challenge will be to personalise screening frequency according to vaccination status. Still the most important factor for successful prevention by screening is high population coverage and organised screening. Screening with self-sampling to reach under-screened women is promising. Progression from HPV infection to cancer takes normally 15–20 years. This long natural history with a prolonged precancerous phase permits early detection and treatment through population screening. Despite screening, invasive cervical cancer remains the commonest female neoplasia in many sub-Saharan African countries and the fourth most common cancer in women globally. An estimate of 570,000 women developed and 311,000 died from cervical cancer in 2018. Of all cervical cancers, 84% of cases and 88% of deaths occur in lower resource countries (human development index <80) where access to preventive care is poor.2 Inevitably it also leads to the early detection of some cancers (that it fails to prevent), which also has a benefit in reducing mortality from cervical cancer. In the UK, incidence of cervical cancer dropped by 24% since the introduction of a national screening programme in 1988.3 Mortality has dropped from 8/100,000 in 1988 to 3/100,000 in 2017.3 In Finland, after introducing the population-based screening in the 1960s, the incidence and mortality have both dropped by 80%. Incidence is presently 4/100,000 and mortality 1/100,000 women years.4 The incidence and mortality trends across counties in Europe and beyond depend on a number of factors from HPV prevalence and ecology to the availability, quality and coverage of screening programmes.Countries with organised screening programmes have reported significant reduction in the incidence and mortality from cervical cancer as a result of treatment of screen-detected lesions.Within the last decade we have seen major advances in cervical cancer prevention both within the proposed screening strategies with the introduction of HPV DNA test as well as the implementation of prophylactic HPV vaccination. This position paper jointly produced by the European Society of Gynecologic Oncology (ESGO) and the European Federation of Colposcopy (EFC) summarises major advances and how these are likely to influence future screening programmes. The statements presented in the paper present summaries of existing guidelines and the best available evidence. If these are not available, the opinion of a team of lead experts in cervical cancer screening and prevention is presented. The references to existing guidelines are included in the relevant sections. In order to produce this statement paper, one or two experts for every section presented in this position paper have been invited to perform a literature search and produce a summary chapter. Each of these chapters were subsequently summarised in this statement paper.5 while the solution can be used for reflex testing for HPV test and other markers. A meta-analysis conducted as part of the European Guidelines for Quality Assurance in Cervical Cancer Screening concluded that although liquid-based and conventional cytology had similar sensitivity and specificity for the detection of CIN2 or worse (CIN2+) at all cytological cut-offs except at cut-off atypical squamou cells of uncertain significance (ASC-US) (where LBC tended to be less specific), LBC was found to improve quality and speed of interpretation allowing further molecular testing.6Exfoliative cytology has been the mainstay for cervical screening. Traditionally, the cells were taken by a spatula or a brush, smeared on glassed slides and stained as first described by Papanicolaou in the ‘40 s. More recently, this has been replaced in some countries by liquid-based cytology (LBC) where the cells are collected with a plastic brush suspended in a fixative-solution. Two collection devices have been validated by Food and Drug Administration (FDA). LBC has a number of advantages. LBC allows a semi-automated production of slides and has the ability to remove debris, red cells, inflammatory cells and artefacts producing a uniform thin spread of epithelial cells that is easier to read by cytopathologists and cytotechnicians. LBC has been shown to reduce the rate of unsatisfactory smears from 9.1% to 1.6% in some settings,7The Bethesda terminology first introduced in 1988 is used for cytology reporting and was updated in 2001 and more recently in 2014. The majority of cervical abnormalities are in squamous cells. Atypical squamous cells of undetermined significance (ASC-US) and low-grade intraepithelial lesions (LSIL) represent the majority of abnormal smears with rates of around 3–5% and 1–2% respectively, while only 0.5–1% of smears are described as high-grade (HSIL). Glandular cells abnormalities are rare and represent 0.2% of all smears and less than 4% of abnormal smears.8 Furthermore, cytology has limitations in detecting glandular intraepithelial lesions located in endocervical glands.9 This is because many do not reach the superficial part of the gland and do not shed exfoliative cells. The incidence of glandular disease and adenocarcinomas has been progressively increasing in some countries with those comprising over 20–30% of cervical tumours. These cancers have poorer prognosis, partly reflecting delays in diagnosis and higher clinical stage.Cytology has also limitations with a 20–25% of false-negative results. Review of new cervical cancer cases revealed most cases (60%) are in women non-compliant with screening, while another 10% in woman managed inappropriately. However, one third of new cancer cases (30%) are women that attended screening and received a negative result due to incorrect sampling or interpretation.Many countries are switching to high-risk HPV (hrHPV) testing for cervical cancer screening, at least in women above the age of 30 and major reorganisation of existing screening strategies is anticipated.10 The benefits are particularly evident in glandular disease. The higher sensitivity permits longer screening intervals, typically 5 years after a negative result, as opposed to the interval for cytology of 3–5 years or even less in some countries. hrHPV is an objective test with low inter- and intra-variability. The test can be run in central laboratories to ensure quality assurance and requires virtually no technical knowledge for reliable results. This alleviates the need for trained cytotechnicians that necessitate training and continuous revalidation for quality assurance that is not feasible in less affluent settings. hrHPV tests further reduces the number of unsatisfactory results at screening and permits self-sampling with comparable sensitivities to physician-collected samples, albeit a slightly lower specificity. Self-sampling may be particularly important for poor compliers and women in rural areas with limited access to health centres.11The use of hrHPV tests as the primary screening modality has several advantages. Several randomised controlled trials and a meta-analysis of randomised data reported Level A evidence that HPV tests have substantially higher sensitivity and negative predictive value in the detection of high-grade disease and when compared to cytology. HPV-based screening has a 60–70% better protection against invasive cervical cancer in women over the age of 30 when compared to cytology.13 The use of hrHPV primary screening in women under 30 years of age is not advised, because of the high prevalence of hrHPV infections in this age group. To improve specificity and minimise over-referral to colposcopy, triage tests are needed to identify infections more likely to be persistent and associated with the development of cancer. Whereas in the past hrHPV testing was expensive, prices of the former have dropped substantially and in some countries with tender procedures for purchasing HPV testing has become cheaper than cytology. Cost-effectiveness analyses have shown that primary hrHPV-based screening is more cost-effective than cytology-based screening as the higher cost of HPV testing is to some extent offset by its higher detection rate and consequent ability to safely screening at longer intervals between tests.15 HPV test may also have adverse psychological sequelae in women that test positive at screening; the type and severity of these will depend on cultural and religious factors and are country-specific.16The major disadvantage of hrHPV testing is its very age -dependent lower specificity when compared to cytology as the test can detect transient HPV infections without a true carcinogenic potential.18hrHPV DNA assays can be applied on vaginal self-samples, which offers opportunities to reach women who do not participate in the regular screening programmes. Meta-analyses have shown that clinically validated PCR-based assays are as accurate on self-compared to clinician-taken cervical samples.With the exception of Hybrid Capture 2 and Cervista, most tests used for HPV detection are PCR-based. Most amplified HPV DNA, major exception is the APTIMA test which is RNA-based. Most tests detect a consensus of 13 high-risk types  associated with cervical cancer and some other cancers. Most of the validated tests have very similar overall characteristics in terms of clinical sensitivity and specificity.19 The laboratory involved in HPV-based screening should perform a minimum of 10,000 HPV tests per year.20Cervical cancer screening program should adopt a hrHPV test for use as screening tool only if it has been clinically validated by demonstrating reproducible, consistently high sensitivity for CIN2+ and CIN3+ lesions, and only minimal detection of clinically irrelevant, transient HPV infections. There is consensus in HPV community that HPV tests  that have not been clinically validated should not be used in clinical practice. HPV testing should be performed only on samples processed and analysed in qualified laboratories, accredited by authorised accreditation bodies and in compliance with international standards.22 Unfortunately, only a subset of commercial HPV tests has documented clinical performance for agreed indications for HPV testing in current clinical practice. For more than 60% of HPV tests on the global market, no single publication in peer-reviewed literature can be identified.22As of December 2019, at least 253 distinct commercial tests for detection of alpha HPVs and at least 425 variants of the original tests are available at the global market.23 listed the hrHPV DNA tests that were either validated through randomised trials showing a very low incidence of cervical cancer after a negative hrHPV DNA test13 or fulfilling international equivalence criteria based on cross-sectional data.24 The international equivalence criteria are based on non-inferior cross-sectional accuracy of a new HPV test versus one of the two benchmark comparator tests (GP5+/6+ PCR-EIA or HC2) that have been validated in clinical trials and detect the same molecular targets, i.e. DNA of hrHPV types.As multitude of hrHPV tests are available, regularly updated evaluation of their suitability for primary screening is essential. A recent systematic review,As of December 2019, a dozen of HPV assays can be considered as validated or partially validated for primary HPV-based cervical cancer screening.HPV-based screening is expected to increase the number of women that will test positive at screening due to lower specificity, especially among younger women, while efforts should be made to optimise triage strategies to prevent overload of colposcopy clinics and unnecessary interventions from passenger transient infections. Triage tests include cellular assays such as cytological findings, p16 with or without Ki67 immunostaining (only on clinician-taken samples), genotyping, viral load and methylation assays (on either self- or clinician-collected samples).25Cytology is the only triage test, for which there is high-grade evidence regarding its suitability to this role. Cytology has been implemented in many settings as a triage test in women testing positive for hrHPV. Reflex cytology of ASCUS or LSIL is the threshold for referral to colposcopy in the European Guidelines, while, if normal, women are retested for HPV in 12 months or for cytology in 6–12 months.Although not yet recommended in the European guidelines, two additional triage tests have been widely evaluated in this context:26 with a PPV as a triage of about 15–20%. HPV33 typically has a similar or higher PPV than HPV16, but it is much less common. HPV31 also emerges as a type with a high PPV, is more common than HPV 33 and could therefore be used to select women who need immediate colposcopy.27 However, the role of HPV16 as the cause of precancer significantly decreases in older women compromising its use in triage.28 HPV18 genotype that is the second most common type in cancer after HPV16 does not perform well in triage. HPV18-associated lesions are common after over 5-year follow-up and most commonly in the endocervix associated with adenocarcinomas, dictating that different approaches might be considered for these lesions. Although this is currently an acceptable triage test in some countries like the US,29 recently published evidence from the English pilot in the UK suggest that 16/18 HPV genotyping in the presence of high-quality cytology and adherence to early recall, does not improve detection of CIN2 or worse.30This is available for HPV16 and 18 in many assays. Performance varies across genotypes and these need to be considered separately. HPV16 is present in 50% of high-grade lesions32 Analysis from randomised evidence33 suggested that if only HPV and p16INK4a immunostaining positive women were referred to colposcopy, referral rate would be similar to that of cytology screening with a 53% increase in detection of CIN2 or worse. More recently other studies have applied the p16INK4a/Ki-67 dual staining technology . Studies have shown that dual staining is more sensitive than cytology in detecting CIN2 or worse in HPV-positive women.35 It could allow a longer interval for HPV+ and p16/ki67− before referral to colposcopy. More studies are needed to clarify its role as a triage test after HPV primary screening.Immunostaining for p16INK4a could be another useful option for the triage of HPV-positive women.Two further tests may prove of use in the triage of HPV-positive women:36 uses hypermethylation of the promoter region of two human genes—the tumour suppressor genes FAM19A4 and/or hsa-mir124–2—and has been commercialised as the Qiasure test (by Qiagen). The second test by a UK group38 includes six genes and uses methylation of both the human genes EPB41L3, MAL1, the viral gene regions of HPV16L1/L2, HPV16E2BS, HPV18L2, HPV31L1 and HPV33L2.There is ongoing research in the field. Only two tests have been fully evaluated. The first from a Dutch group41 but also other HPV types at different degree. Although available for many HPV tests (relative light units for HC2 and CT scores for PCR-based tests), further studies should validate its use to ensure values are appropriately adjusted for number of cells per sample.Several papers have shown viral load to be an important quantifier of risk particularly of HPV16,42Although the possibility of combination test may improve accuracy of triage, these combinations may not apply or be possible for all tests and can be costly and time-consuming, and hierarchical modelling may allow multiple testing only for equivocal results. With self-sampling becoming a possibility in some screening settings, emphasis should lie on viral  rather than cytological triage markers, and other molecular tests (e.g. p16 and mRNA) may also be proved to be useful.43 The second edition published in 20088 defined the following necessary components of an organised screening program: defined target populations (women 25–65 years of age) and screening intervals (3–5 years if using Pap-smears and 5–7 (10) using hrHPV-test), use of a population-based registry and appropriate recruitment measures, like personal invitations and place and date for the taking of the screening test, definition of the screening test, adequate facilities to perform this test, defined management algorithms and monitoring and evaluation of the process and impact of screening. A supplement of 2nd edition published in 2015 recommends the integration of new technologies such as HPV-based screening and vaccination in the programs for cervical cancer control.19European Guidelines for Quality assurance in Cervical Cancer Screening established principles of organised, population-based screening.The success of any screening in general, regardless of the methodology applied, is directly related to quality control of the program, and above all high population coverage. The principles of quality control and key performance indicators should be known by all involved stakeholders and health professionals.The recommendations shown in Table At this stage it is unclear what should be the recommended age at first screen, the importance of the specifics of the local epidemiology  or even the optimal frequency of screening events. Moreover, although theoretically we anticipate that the screening requirements of the vaccinated cohorts will be significantly reduced, we have limited empirical data to consolidate formal ESGO recommendations. More documented guidance should be available as vaccinated cohorts arrive at a range of first screening age (i.e. 25–35) in the coming few years.Cost-effectiveness analyses can be used to integrate information about screening algorithms from trials and cross-sectional studies to project their long-term outcomes. Such analyses can show the trade-offs between greater reductions in cervical cancer cases and deaths on the one hand, and on the other hand, more positive tests, colposcopies and treatments, which may diminish women’s quality of life and increase costs.44 Most studies also show that HPV as the sole primary screen is more cost-effective than using it for cotesting with cytology.46 A key driver of cost-effectiveness is the fact that HPV DNA testing allows a longer interval between screens without increasing the risk of cancer.In high-income countries, most economic evaluations have found using HPV test as the primary screen  was more cost-effective than cytology alone.48HPV prevalence: Lower population HPV prevalence (such as in vaccinated populations or older women) improves the cost-effectiveness of HPV testing when compared to cytology.49Costs: High-volume centralised laboratories can save costs.HPV-test characteristics: HPV testing kit sensitivity and specificity and testing methodology (e.g. self-collected vs. provider-collected specimens) may influence cost-effectiveness and likely uptake.50Quality of life: The assumed impact of positive HPV tests, colposcopies and treatment for neoplasia on quality of life can influence cost-effectiveness.However, results differ across settings and studies because of differing assumptions around key model inputs, such as:Based on economic and other evidence, several countries have introduced or are in the process of introducing primary HPV testing into cervical screening algorithms Table .Table 2SIn conclusion, most studies suggest that HPV testing is more cost-effective than either cytology or cotesting as the primary screen. Cost-effectiveness analyses can help optimise primary HPV testing algorithms in their choice of triage test, interval between screens and age of screening in order to maximise the ratio of benefits to harms of screening within a particular setting.The vaccine is purely prophylactic so that women already infected with an oncogenic HPV are not protected by the vaccine for that type. Since very few women (anywhere in the world) born before 1992 were vaccinated before they became sexually active, there will be a need to screen cohorts not offered vaccination for the foreseeable future (most likely until about 2060).51Not all women receive the vaccine. Although unvaccinated individuals within vaccinated cohort may benefit from herd immunity, particularly when the coverage is high, it is clear that unvaccinated women will not be fully protected against HPV infection and cervical cancer for some years.52 The new nonavalent vaccine (Gardasil9) with the additional five types (31/33/45/52/58) should prevent about 90% of cervical cancer in vaccinated women, but there is still a question on how to screen vaccinated cohortsThe current vaccines do not protect against all HPV types that cause cervical cancer. The two first generation vaccines offered excellent protection against HPV16/18 with some cross-protection against other among subjects who did not carry these HPV types.54 the vaccines are relatively new and there is no data on whether a vaccine given at age 12 will still protect women from infection 15–25 years later.Although there is no evidence of waning efficacyCervical screening should continue in the era of HPV vaccination for the following reasons:57 Additionally, continued monitoring of a cohort of women who were vaccinated early on is important so as to be able to adapt screening programmes should vaccine efficacy be shown to wane.Corresponding to these reasons, there is a need to consider screening in four groups: cohorts not offered vaccination; unvaccinated women within vaccinated cohorts; vaccinated women and vaccinated cohorts in whom it is not known who has and has not been vaccinated.58 HPV 16 and 18 account for about 70% of cancers but for just 30% of high-risk HPV infections in screened women.59 HPV16/18 prevalence in CIN2+ is in between these figures. Thus, the positive predictive value of both high-risk positivity and low-grade cytological abnormalities is greatly reduced in vaccinated women.60HPV vaccination provides an additional impetus for the use of HPV test in primary screening. If HPV type 16 and 18 infections, lesions and cancers are removed from the population, this will affect the test performance of both cervical cytology and HPV testing.56 In a cohort some of whom have been vaccinated, the specificity of HPV testing (and typing) at identifying those who have not been protected against HPV16/18 and are at greatest risk (because they have an HPV16/18 infection) is such that virtually everyone recommends HPV testing over cytology for such women.61Vaccination will reduce the prevalence of precancer in the screening population. That will mean that the numbers needed to screen to find one precancer will increase. Since cytology is subjective, this will cause additional challenges for cytoscreeners.Screening will not require adjustment for women too old to have been offered HPV vaccination are unlikely to benefit from vaccination of younger women because birth-cohorts far apart in age are only weakly linked through sexual networks, so these women benefit little from herd protection, and because the majority of those who would be at risk of cervical cancer will have been infected by HPV before vaccination became widespread.Although herd protection is likely to reduce the risk of HPV infection and cervical cancer in unvaccinated women living in a vaccinated population, the magnitude and timing of such protection is still unclear. Women known not to have been vaccinated may be screened as before vaccination until there is greater evidence accumulates.56Since the lifetime risk of cervical cancer in women vaccinated against HPV is substantially lower than in unvaccinated cohorts, one could consider less frequent screening. Additionally, HPV 16 is the most carcinogenic HPV type, it makes sense to extend the screening interval and/or start screening at older age.By lack of linkage between HPV vaccination and screening data basses it is impossible to differentially invite women depending on their individual vaccination status. As one would anticipate, the screening recommendations for partially vaccinated populations would be intermediary between those for unvaccinated and those for vaccinated populations.In summary, screening will have to continue for decades to account for non-vaccinated/partially vaccinated cohorts. In HPV vaccine times HPV screening will replace cytology as primary screening test. Before several cohorts are intensively vaccinated, discrimination of screening protocols as function of the vaccination status of the individuals seems to be impractical in most settings. Protocols for HPV-based screening tend to target women over 30 and be offered every 5–7 years, a critical component of the sustainability of the programs under intensive research. Further ongoing research explores how impact of the vaccines can be accelerated with vaccination of adult women and high-risk groups, while reduction of cost and ensuring that there is no shortage of vaccines may further advance efforts for cervical cancer elimination in the future. Prophylactic vaccines do not have a role in women with existing HPV infections and/or preinvasive disease. A number of therapeutic vaccines in women with existing cervical disease are currently under investigation.In the era of rapid changes with HPV-based screening and prophylactic vaccination, screening strategies are undergoing major restructure. This document summarises the current position of ESGO and EFC in relation to cervical screening. More specifically, we discuss the advantages of HPV-based screening, the challenges in the triage of HPV-positive women and cost-effectiveness of HPV-based programmes. Quality assurance benchmarks are essential. HPV-based screening is likely to undergo further changes in vaccinated cohorts with prolonged intervals between tests. Education of women on the importance of screening should continue.


Uptake and completion of the HPV vaccine is suboptimal. This study assessed the feasibility of implementing a one-month Twitter campaign to promote knowledge about the human papillomavirus (HPV) vaccine among low-income women living in public housing.n = 35) of women ages 18–26 years residing in low-come, public housing in Massachusetts. We assessed the feasibility and acceptability of a communication campaign that consisted of daily Twitter messages. Online surveys assessed changes in HPV knowledge, attitudes, and vaccine intentions before and after the campaign.We recruited a convenience sample (Most believed that Twitter was an acceptable educational strategy and remained engaged with the campaign throughout the intervention. We observed no changes in HPV knowledge, perceived benefits of or barriers to vaccination, decision self-efficacy, or vaccine intentions after the campaign, although perceived risk for cervical cancer decreased.Twitter may be a feasible and acceptable method for promoting knowledge about the HPV vaccine, but more research is needed to understand how best to reach low-income women with low levels of vaccine uptake.Clinicaltrials.gov 1,603,045, retrospectively registered 0610/19. The American Cancer Society estimated that, in 2018, there were 13,240 new cases of invasive cervical cancer and 4170 cervical cancer deaths among women in the United States  would it be to receive the HPV vaccine?” with response options on a 4-point Likert scale  [nsive]”) . “Don’t Decision self-efficacy with regard to obtaining and comprehending information about the vaccine was assessed with 11 items adapted from the Decision Self-Efficacy Scale [How confident do you feel to get the facts about the risks of the HPV vaccine?). Responses were on a 2-point Likert scale . Total points were then divided by the maximum number of points and multiplied by 100 to arrive at a scale with a range of 0–100%, with higher scores indicating higher confidence.cy Scale   also completed the post-test survey and 7 initiated, but did not complete the post-test survey. At the time of enrollment, approximately half (57%) had an existing Twitter account. About a third (36%) of those with an existing Twitter account said they checked on a daily basis, although a higher percentage (45%) said they checked every few weeks or less. During the campaign, six of the women “liked” our Tweets and four of the women “retweeted” our messages . Of the 35 women who completed the study, only 2 (5.7%) ‘blocked’ our tweets during the campaign. At post-test, 71% of women agreed with the statement “Participants who completed both surveys ranged in age from 18 to 26 years . About two-thirds (63%) had household incomes below $50,000/year, two-thirds (61%) had at least some college education, half (54%) had public insurance, and the majority (91%) were single. Half (51%) were black or African American, and 40% were born outside of the U.S. from a wide variety of countries with highest percentage from Caribbean (20%). Less than half (40%) had received a Pap test in the last 3 years. The majority (94%) was aware of HPV infection, and 63% had received 3 doses of the HPV vaccine.p = 0.858). Perceived risk of developing cervical cancer was low and decreased at post-test , although this change was no longer statistically significant in subgroup analyses among women who verified receipt of messages. Participants generally perceived that there were high benefits to HPV vaccination in terms of vaccine efficacy  and vaccine safety . They tended to report that there were only moderate barriers to HPV vaccine uptake . HPV vaccination decision self-efficacy was high and did not change after the campaign . We observed no statistically significant change in the intent to be vaccinated in the next 6-months (p = 1.000) or 12-months (p = 0.617) after the campaign among those who had not yet started or completed vaccination.Before the campaign, HPV knowledge scores were low, and we observed no statistically significant change after the campaign  had high vaccine completion at baseline. It is possible that this high uptake is a result of good access to healthcare in Massachusetts. Massachusetts passed healthcare reform in 2006, with the goal of providing health insurance to most residents. The law mandates that Massachusetts provide free or subsidized healthcare insurance for residents earning less than 150 and 300% of federal poverty level. As a result, residents of Massachusetts have greater access to preventive health care compared with other states.Alternatively, it could be that Twitter users are more willing to get the vaccine. The only other Twitter-based HPV vaccination intervention study that we identified, which also did not find any effect of the intervention on HPV vaccine uptake among women, also observed high levels (85%) of HPV vaccine completion at baseline . Thus, aNotably, the use of Twitter in our sample was lower than for the general population in this age group (22%). Twitter use is generally higher among those under age 50 years and those living in urban rather than rural areas , which lIn addition to considering alternative social media platforms, it is unlikely that dissemination of information alone will change HPV vaccine behaviors. The Community Guide recommends that cervical cancer interventions utilize multiple components, such as group education . Women iMore research is needed to assess the messages, dose, and social media platform that most effectively facilitate HPV vaccine knowledge and uptake in socially and economically marginalized populations at risk of cervical cancer , 34. Mor


HPV16  and α-9 genera  were associated with less relapse. In the multivariate analysis, only the International Federation of Gynecology and Obstetrics (FIGO) stage retained an independent prognostic value. HPV16, α-9 genera and p16 overexpression were associated with better survival, although not as independent prognostic factors. Patients with p16-negative HPV-associated CC were older, presented with advanced disease and had worse prognosis.The expression of p16 is a good surrogate of human papillomavirus (HPV) infection in HPV-associated cancers. The significance of p16 expression, HPV genotype and genera in the outcome of patients with HPV-associated cervical cancer (CC) is unclear. Our aim is to ascertain the prognostic significance of these factors. Data from 348 patients (median age: 47.5 years old) with CC, diagnosed in two referral centers, were retrospectively collected. Advanced disease (FIGO2018 IB2-IV) was present in 68% of patients. A single HPV genotype was identified in 82.8% of patients. The most common HPVs were HPV16 (69%) and HPV18 (14%). HPV genera reflected this distribution. HPV16 tumors presented at an earlier stage. P16 was negative in 18 cases (5.2%), 83.3% of which were squamous cell carcinomas. These cases occurred in older patients who tended to have advanced disease. In the univariate analysis, HPV16 (HR: 0.58;  Human papillomavirus (HPV) is etiologically involved in most cervical cancers (CCs) ,2,3 and Almost all studies, even those using highly sensitive HPV tests, identify a small proportion of CCs negative for HPV ,13,14. RThe immunohistochemical overexpression of p16 has been considered to be a good surrogate for HPV infection. Diffuse and strong p16 staining is consistently present in almost all HPV-associated cancers, whereas HPV-independent tumors are typically p16 negative ,21. Due Finally, the prognostic value of the HPV genotype is still unclear, largely because previous studies have yielded conflicting results. Studies on the prognostic value of the most prevalent high-risk HPVs, namely HPV 16 and 18, revealed contradictory positive and negative associations ,15,28,29This study on HPV genera and genotypes and the p16 prognostic value in HPV-associated CC gathers data from two cohorts of patients, with a long follow-up period of two tertiary referral centers in Portugal and Spain. Partial results from both cohorts have been previously published and include the association between p16 expression and better prognosis ,32. Our n = 237) of the patients presented with advanced disease  stages 2018 IB2-IV) and 26% (n = 92) with lymph node metastases. A total of 348 women with HPV-associated CC were included in this study. The median age at diagnosis was 47.5 years (range: 22–89 years). The most common histological type of CC was squamous cell carcinoma (80%), followed by adenocarcinoma (19%) and four other rarer subtypes (three adenosquamous carcinomas and one neuroendocrine carcinoma). At the time of diagnosis, 68% (The distribution of HPV genotypes and genera among the 348 patients with HPV-associated CC is shown in p = 0.08). HPV16 tumors were more likely to present with early disease (36%) compared to non-HPV16 tumors (23%) (p = 0.02). The number of patients who presented with lymph node metastases at diagnosis was similar between the HPV16 and non-HPV16 groups . The association between HPV16 detection and histological type was not significant . HPV18 was more frequently detected in adenocarcinomas than in squamous cell carcinomas .HPV16 was identified in 241 (69.0%) tumors (single or multiple infections). The median ages at diagnosis of patients with HPV16 and non-HPV16 tumors were 46 and 49 years, respectively (p = 0.05) with advanced disease . Most p16-negative tumors were squamous cell carcinoma (SCC) (83.3%), and the remaining four cases were ADC (16.7%). Regarding the HPV genotypes of p16-negative tumors, eleven cases (61%) had HPV16 infection. Two p16-negative cases had multiple infections with HPV16, HPV31, HPV16 and HPV33. The four p16-negative adenocarcinomas had single HPV infections. In two cases each, HPV18 and HPV16 were identified. In the remaining four cases of this subgroup , two harbored other high-risk HPV genotypes (HPV56 and HPV33), and a probably high-risk genotype (HPV70) and low-risk HPV genotype (HPV6) were found in one case each. Accordingly, the HPV genera of the p16-negative tumors were mainly α-9 (67%), followed by α-7 (17%), non-α-9 non-α-7 (11%) and unknown genera (6%).Of all the 348 tumors, 18 (5%) were p16 negative. The clinicopathological characteristics  of the p16-positive and p16-negative tumors are shown in No significant statistical differences were found between the p16-positive and p16-negative subgroups regarding the center of origin, histology, presence of lymph node metastases or HPV genotype and genera . n = 109) of the patients had disease relapse, and 22% (n = 78) patients died due to disease progression. A total of 35 (10%) patients died due to non-CC-related causes and 6 from unknown causes (2%). The median 5- and 10-year disease-free survival (DFS) rates were 67.8% (95% CI: 62.8–73.2%) and 65.4% (95% CI: 60.2–71.1%), respectively. The median 5- and 10-year disease-specific survival (DSS) rates were 75.9% (95% CI: 71.2–81%) and 74.3% (95% CI: 69.3–79.6%), respectively.After a median follow-up of 111.6 months (95% CI: 95.7–130.7 months), 31% (p = 0.017) and DSS rates  than patients with tumors associated with other HPV types (p = 0.016) but not in ADC (p = 0.98).Patients with HPV16-associated tumors had significantly better five-year DFS , but no difference between five-year DFS rates were observed between tumors with and without p16 overexpression   . In the univariate survival analysis, the presence of HPV16 genotype, p16 overexpression and α-9 genera were significantly associated with better survival . Tumors On multivariate analysis, only the early FIGO stage remained associated with better survival and a lower risk of disease relapse .In this study, we reviewed 348 cases of HPV-associated invasive CCs with prolonged follow-up (median: 9.25 years) and evaluated HPV genotypes, genera and p16 expression. We adjusted the survival analysis for age at diagnosis and FIGO stage 2018.As previously reported ,11, the There are contradictory data regarding the significance of HPV genotypes on the clinical outcome of patients with HPV-associated cervical cancer ,36. SeveClustering HPV genotypes into their genera could be clinically more relevant. HPV α-7-positive CC, which includes HPV18, has been associated with worse local control after radiotherapy, relative to HPV α-9-positive cases, which include HPV16 . In thisIn this cohort, 5% of HPV-associated invasive CC were p16 negative. A variety of mechanisms could explain the negativity of p16 in HPV-associated carcinomas. Loss of heterozygosity has been reported in HPV-associated carcinomas, as have point mutations of CDKN2A or the silencing of the CDKN2A gene by promoter hypermethylation of the promoter ,38,39,40Inactivation of p16INK4a has been associated with more aggressive behavior in several cancers ,43,44. HThis is a retrospective study conducted in two tertiary referral centers (Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E. (IPOLFG) and the Hospital Clinic of Barcelona (HCB) regarding 348 patients with HPV-associated CC, diagnosed between 1980 and 2016 and 1999 and 2016 in the Lisbon and Barcelona centers, respectively. The Portuguese cohort included all consecutive cases diagnosed during the months of March and April in the pair-years of the 1980, 1990 and 2000 decades. Since 2005, all cases of CC with the inclusion criteria were included. Cases were not selected by organized screening practices. The Spanish cohort included all women with CC admitted to the Gynecological Oncology Unit of the Hospital Clinic of Barcelona from January 1999 to January 2016. The inclusion criteria were: (1) histologically confirmed diagnosis of CC, (2) a paraffin block with an available tumor tissue for HPV DNA genotyping and p16 immunostaining and (3) positive result of the HPV DNA test. Clinical features and follow-up were recorded, and pathological parameters were reviewed. Tumors were restaged (SM/AF and IN) according to the 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system. Lymph node metastasis status was determined either on the histopathologic result or the interpretation of radiologic imaging (computerized tomography/magnetic resonance imaging or positron emission tomography with F18-fluorodeoxyglucose) of pelvic and/or para-aortic lymph nodes. Cases with disease persistence after initial treatment were excluded from this study.Data collection and analysis were approved by the Ethical Committees of each institution . Patient consent was waived due to the retrospective nature of the study and the analysis used anonymous clinical data.The IPOLFG series collected a large span of patients diagnosed and treated from 1988 to 2016. Patients with early-stage cervical cancer diagnosed before 1998 underwent loop electrosurgical excision or brachytherapy followed by radical hysterectomy and, in selected cases, pelvic and/or para-aortic lymph node dissection. Since 2000, patients with adverse risk factors  received adjuvant radiotherapy or chemoradiotherapy. Advanced-stage patients received radiotherapy or chemoradiotherapy. Clinical follow-up was performed every 3 months for 2 years, every 6 months from 2 to 5 years and annually thereafter. The treatment and follow-up strategy for the 190 patients from the HCB cohort has been described in detail elsewhere , but a sTumor samples of formalin-fixed, paraffin-embedded tissue from biopsies or surgical specimens were stained with hematoxylin and eosin and p16 immunohistochemistry. For the IPOLFG cases, tissue microarrays were made, each represented by 3 cores of 1.5 mm in diameter, retrieved from different areas of the tumor. The human monoclonal p16 antibody, clone E6H4 , was used, following the manufacturer’s protocol . Cases with diffuse and strong nuclear and cytoplasmatic staining in all viable tumor cells were considered positive for p16. Cases with irregular or focal staining were considered negative .DNA extraction was performed in formalin-fixed, paraffin-embedded tissue. Isolated DNA was used for HPV detection and genotyping with SPF10 PCR-DEIA-LiPA25 system  . This pln = 4), and with an unknown cause of death (n = 6) were excluded from the survival analysis. Disease-free survival (DFS) was defined as the time from diagnosis to first recurrence , regardless of the recurrence site. Disease-specific survival (DSS) was defined as the time from diagnosis to death from disease. Patients without follow-up information concerning disease relapse (n = 17).For analysis purposes, FIGO staging was grouped in early (stages IA1 to IB1) and advanced (stages IB2 to IV) cervical cancer. Cases with a single HPV type were considered as single HPV infections, whereas cases with two or more HPV genotypes were classified as multiple HPV infections. Cases with HPV X were excluded from the analysis of single vs. multiple infections. For HPV genotype analysis purposes, HPV-16-positive tumors included single or multiple HPV 16 infections, and all remaining genotypes, including HPV X, were considered as non-HPV 16 types. Patients with HPV-associated cancer with an undetermined genotype were considered to have an unknown genus , HPV genotype (HPV 16 vs. other) and HPV genera (α-7 vs. α-9 vs. α-7 and α-9 vs. other genera). We conducted univariate and multivariable analyses controlling for the potential confounders FIGO stage and age at diagnosis. Cox model assumptions were checked using the Schoenfeld residuals to test the proportional hazards assumption and the Martingale residuals to check the functional form of the age covariate. We considered a significance level of 5% and did not make any adjustment for multiple comparisons. All analyses were performed with R , using tIn our series, HPV16, α-9 genera and p16 overexpression were associated with better survival in patients with HPV-associated CC, although we could not validate the independent prognostic value of these factors. Our results confirm the existence of a small number of HPV-associated CCs that do not overexpress p16 (5%). These patients tend to be older and present with advanced disease, both of which are poor prognostic factors. As our and previous results reflect the same prognostic trend for p16, the small number of cases negative for p16 could be partially responsible for the lack of statistical significance on multivariate analysis. This subpopulation warrants more studies to be better characterized.