Michael Shier

Cervical Screening: A Guideline for Clinical Practice in Ontario

OBJECTIVE To develop guidelines to inform the Ontario Cervical Screening Programs invitations to women in the target population, provide evidence-based clinical practice guidance for practitioners, and inform policy decisions. METHODS A systematic review was conducted of relevant websites, the Medline and EMBASE databases (2005 to November 2010), and the Cochrane Library (2005 to 2010). No guidelines or systematic reviews were located that addressed the topics of interest. The evidence base consisted of seven randomized controlled trials, three case-control studies, one cohort study, and one review article. A methodologist performed data identification and extraction. Review of the data and quality assessment was carried out by the authors, who have expertise in methodology, gynaecologic oncology, pathology, and family medicine. The systematic review methods and resulting recommendations were reviewed by an internal panel with clinical, methodological, and oncology expertise. External review was provided by Ontario clinicians and other experts. CONCLUSIONS The guideline development process led to recommendations for the optimal primary cervical screening method, screening interval, and age of screening cessation for Ontario women in the target population. There was insufficient evidence to provide a recommendation for age of initiation of cervical screening with HPV testing. The creation of an organized screening program in the province will allow the implementation of evidence-based recommendations. We provide interim recommendations for cervical screening until HPV testing has been funded.

Colposcopic management of abnormal cervical cytology and histology.

OBJECTIVE To provide a guideline for managing abnormal cytology results after screening for cervical cancer, to clarify the appropriate algorithms for follow-up after treatment, and to promote the best possible care for women while ensuring efficient use of available resources. OUTCOMES Women with abnormal cytology are at risk of developing cervical cancer; appropriate triage and treatment will reduce this risk. This guideline will facilitate implementation of common standards across Canada, moving away from the current trend of individual guidelines in each province and territory. EVIDENCE Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in October 2008 using appropriate controlled vocabulary (e.g., colposcopy, cervical dysplasia) and key words (e.g., colposcopy management, CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical dysplasia triage). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Expert opinion from published peer-reviewed literature and evidence from clinical trials is summarized. Consensus opinion is outlined when evidence is insufficient. VALUES The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). VALIDATION This guideline has been reviewed for accuracy from content experts in cytology, pathology, and cervical screening programs. Guideline content was also compared with similar documents from other organizations including the American Society for Colposcopy and Cervical Pathology, the British Society for Colposcopy and Cervical Pathology, and the European Cancer Network.

HPV Testing in Primary Cervical Screening: A Systematic Review and Meta-Analysis

OBJECTIVE Previous findings from cross-sectional studies have shown human papillomavirus (HPV) testing to be more sensitive than cytology testing for primary cervical screening. This systematic review aims to assess whether the increase in baseline detection with HPV testing corresponds to lower rates in subsequent screening rounds. METHODS We searched Medline, EMBASE, and the Cochrane Library for randomized controlled trials (published from 2005 to 2010) comparing HPV-based and cytology-based cervical screening. Primary outcomes of interest were relative rates of higher grade cervical intraepithelial neoplasia and invasive cervical cancer. Secondary outcomes included test performance characteristics and colposcopy referral rates. Results were pooled where possible using a random effects model. RESULTS Seven randomized trials were identified. Across studies, HPV testing was more accurate than conventional cytology and detected significantly more CIN3+ in the first screening round (Mantel-Haenszel [M-H] risk ratio 1.67; 95% CI 1.27 to 2.19) and significantly less in the second screening round (M-H RR 0.49; 95% CI 0.37 to 0.66). There were no differences in pooled rates of CIN2+ (M-H RR 1.19; 95% CI 0.94 to 1.50) and CIN3+ (M-H RR 1.09; 95% CI 0.84 to 1.42), but there was a higher pooled rate of CIN2 (M-H RR 1.37; 95% CI 1.12 to 1.68) over two screening rounds. A trend towards lower rates of invasive cervical cancer was observed. CONCLUSION Organized screening programs in higher resource settings should consider adopting HPV testing as the primary screening test for women 30 or 35 years of age and older. Further research is needed to determine optimal screening strategies for younger women.

Canadian Consensus Guidelines on Human Papillomavirus

OBJECTIVE To serve as a guideline for health care providers on the use of continuous and extended combined hormonal contraception regimens, to prevent pregnancy, and to delay menses that affect health-related quality of life. OPTIONS All combined hormonal contraceptive methods available in Canada that may be used in a continuous or extended regimen are reviewed, and the implications are discussed. OUTCOMES Efficacy of cited regimens and assessment of their side effects, patient safety, medical usage and non-contraceptive benefits, cost-effectiveness, and availability in Canada. Indications for patient counselling are also provided. EVIDENCE Medline, PubMed, and Cochrane Database were searched for articles published in English between 1977 and May 2007. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. VALUES The quality of evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS The guideline is intended to help reduce unintended pregnancies and improve health-related quality of life in women who find their menses problematic. Increased awareness and empowerment of women, their partners, and health care professionals will improve their ability to make appropriate choices between continuous or extended and cyclic usage of these regimens. SPONSORS The development of this guideline has been supported by unrestricted grants from Bayer HealthCare Pharmaceuticals, Janssen Ortho, Organon Canada Ltd., Paladin Labs Inc., Pfizer Canada Inc., and Wyeth Pharmaceuticals.Objective: To promote guidelines for health care providers on the key aspects of HPV infection and the management of HPV-related disease in the new era of vaccine availability.

Giant condyloma versus verrucous carcinoma: a case report.

Giant condyloma acuminatum is a large, slow-growing, exophytic, cauliflower-like tumor of the external genitalia. It is a histologically benign lesion, largely associated with human papillomavirus infection but with a high recurrence rate. The main differential diagnosis includes verrucous carcinoma. Differentiation between these 2 types of tumors is important with respect to treatment and prognosis. We present a case report of a 26-year-old woman with giant condyloma acuminata of the vulva and discuss the histological features and treatment modalities of this condition.

A Novel Approach to the Surgical Management of Clitoral Phimosis

BACKGROUND The objective of this case series was to outline a novel method for surgical correction of clitoral phimosis caused by vulvar lichen sclerosus (LS) or lichen planus (LP) and to review the postoperative outcomes. CASE SERIES We used the CO2 laser to treat clitoral phimosis in 20 women with LS and three women with LP. All patients underwent individualized preoperative and postoperative topical therapy with steroids or immunomodulators. Five women with LS had mild reagglutination during follow-up but were satisfied with the results, and three required reoperation, with satisfactory results in follow-up. Two women with LP required reoperation. CONCLUSION This novel surgical technique has enabled the treatment of clitoral phimosis secondary to LS or LP, but further studies are required. Medical maintenance therapy postoperatively is a vital component of treatment.

The optimum organization for the delivery of colposcopy service in Ontario: a systematic review.

Objective: To determine the optimum organization for colposcopy service delivery in Ontario, Canada. Methods: A multidisciplinary expert panel was convened to develop a systematic review to inform organizational guidelines. MEDLINE, EMBASE, CINAHL, HealthSTAR, and the Cochrane Library databases were searched from 1996 to February 2006 for articles that reported guidance or outcomes relating to improved outcomes in colposcopy training, qualifications, accreditation, maintenance of competency, the delivery of colposcopy, reducing default from colposcopy clinics, and/or strategies to improve patient satisfaction or comfort. In addition, an environmental scan identified unpublished documents related to the delivery of colposcopy services. Results: Sixteen guidance documents related to the delivery of colposcopy services were identified; 5 from the published literature and 11 from the environmental scan. These documents were used by the panel to inform the systematic review and companion guidelines. Conclusions: Overall, the Ontario Colposcopy Guidelines Development Group believes that the benefits associated with the implementation of colposcopy recommendations in Ontario will result in greater organization of care and improved patient outcomes. In addition, the group anticipates that these recommendations will provide useful guidance to regional planning authorities, hospital administrators, and Cancer Care Ontario, as well as colposcopists and other practitioners, in the planning of integrated regional and provincial cancer screening services.

Prise en charge colposcopique des résultats cytologiques et histologiques anormaux en ce qui concerne le col utérin

Resume Objectif Fournir une directive clinique traitant de la prise en charge des resultats cytologiques anormaux issus du depistage du cancer du col uterin, clarifier les algorithmes appropries aux fins du suivi a la suite du traitement et promouvoir l’offre des meilleurs soins possibles aux femmes tout en assurant une utilisation efficace des ressources disponibles. Issues Les femmes qui obtiennent des resultats cytologiques anormaux sont exposees a un risque de voir apparaitre un cancer du col uterin; la mise en œuvre d’un triage et d’un traitement appropries attenuera ce risque. La presente directive clinique facilitera la mise en œuvre de normes communes a la grandeur du Canada, et ce, en vue de contrer la tendance actuelle qui veut que chaque province et territoire formule ses propres lignes directrices. Resultats La litterature publiee a ete recuperee par l’intermediaire de recherches menees dans PubMed ou Medline, CINAHL et The Cochrane Library en octobre 2008 au moyen d’un vocabulaire controle (p. ex. « colposcopy », « cervical dysplasia ») et de mots cles (p. ex. « colposcopy management », « CIN », « AGC », « cervical dysplasia », « LEEP », « LLETZ », « HPV testing », « cervical dysplasia triage ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n’a ete appliquee en matiere de date ou de langue. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu’en juillet 2012. La litterature grise (non publiee) a ete identifiee par l’intermediaire de recherches menees dans les sites Web d’organismes s’interessant a l’evaluation des technologies dans le domaine de la sante et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et aupres de societes de specialite medicale nationales et internationales. Les opinions de specialistes issues de la litterature publiee soumise a l’examen collegial et les donnees issues d’essais cliniques sont resumees. Une opinion de consensus est presentee lorsque les donnees sont insuffisantes. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits par le Groupe d’etude canadien sur les soins de sante preventifs (Tableau). Validation La precision de la presente directive clinique a ete analysee par des specialistes œuvrant dans les domaines de la cytologie, de la pathologie et du depistage cervical. Le contenu de la presente directive clinique a egalement ete compare a celui de documents similaires issus d’autres organisations, dont l’ American Society for Colposcopy and Cervical Pathology , la British Society for Colposcopy and Cervical Pathology et l’ European Cancer Network .

Lichen scléreux vulvaire

Un diagnostic de lichen sclereux s’accompagnant d’une hyperplasie squameuse benigne connexe a ete etabli (auparavant connu sous le nom de dystrophie vulvaire mixte). Bien que le lichen sclereux affecte plus souvent la vulve des femmes postmenopausees, il peut se manifester a tout âge (y compris pendant l’enfance) et peut, quoique moins frequemment, affecter d’autres sites cutanes. Le traitement au moyen de corticosteroides surpuissants topiques et de progesterone topique a permis de soulager les symptomes, et la participation de la patiente a un programme de surveillance a long terme a ete sollicitee.

Extramammary Paget's disease of the vulva.

Extramammary Paget’s disease is a rare neoplastic disorder involving skin bearing apocrine glands . On the vulva it can be intraepithelial or less commonly have an invasive component, and accounts for less than 1% of vulvar neoplasms.1 The more common intraepithelial lesion is classified by the International Society for the Study of Vulvar Disease as a type of non-squamous vulvar intraepithelial neoplasia. Differential diagnosis includes seborrheic dermatitis, psoriasis, fungal infection, and atopic dermatitis.