Comment

In the meantime, who should receive dose-intensied treatment? Rcher and colleagues report convincing evidence that patients younger than 59 years with an International Prognostic Index of 1, who can tolerate the additional toxic eects of R-ACVBP with consolidation, do have a better 3-year event-free survival. Unfortunately, some of the drugs in the regimen are not available in all countries and testing of substitute drugs or modications would be needed. Furthermore, a direct comparison of other dose-intensive chemotherapy regimens such as a dose-adjusted regimen of rituximab, etoposide, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH)11 versus the R-ACVBP regimen is needed, pending the results of the present R-CHOP versus dose-adjusted R-EPOCH protocol being done by the United States Cooperative Group Mechanism (registered with ClinicalTrials.gov, number NCT00118209). Although we continue to identify subsets of patients at higher risk, further international clinical trials are needed to assess the best individualised approach to treatment for these patients. Julie M Vose
Division of Hematology/Oncology, Nebraska Medical Center, Omaha, NE 68198, USA jmvose@unmc.edu
I declare that I have no conicts of interest.

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Rcher C, Coier B, Haioun C, et al, for the Groupe dEtude des Lymphomes de lAdulte. Intensied chemotherapy with ACVBP plus rituximab versus standard CHOP plus rituximab for the treatment of diuse large B-cell lymphoma (LNH03-2B): an open-label randomised phase 3 trial. Lancet 2011; 378: 185867. The International Non-Hodgkins Lymphoma Prognostic Factors Project. A predictive model for aggressive non-Hodgkins lymphoma. N Engl J Med 1993; 329: 98794. Pfreundschuh M, Trumper L, Osterborg A, et al. CHOP-like chemotherapy plus rituximab versus CHOP-like chemotherapy alone in young patients with good-prognosis diuse large-B-cell lymphoma: a randomised controlled trial by the MabThera International Trial (MInT) Group. Lancet Oncol 2006; 7: 37991. Tilly H, Lepage E, Coier B, et al. Intensive conventional chemotherapy (ACVBP regimen) compared with standard CHOP for poor-prognosis aggressive non-Hodgkin lymphoma. Blood 2003; 102: 428489. Rosenwald A, Wright G, Chan WC, et al. The use of molecular proling to predict survival after chemotherapy for diuse large-B-cell lymphoma. N Engl J Med 2002; 346: 193747. Aukema SM, Siebert R, Schuuring E, et al. Double-hit B-cell lymphomas. Blood 2011; 117: 231931. Casasnovas RO, Meignan M, Berriolo-Riedinger A, et al. SUVmax reduction improves early prognosis value of interim positron emission tomography scans in diuse large B-cell lymphoma. Blood 2011; 118: 3743. Nowakowski GS, Laplant B, Habermann TM, et al. Lenalidomide can be safely combined with R-CHOP (R2CHOP) in the initial chemotherapy for aggressive B-cell lymphomas: phase I study. Leukemia 2011; published online July 1. DOI:10.1038/leu.2011.165. Ruan J, Martin P, Furman RR, et al. Bortezomib plus CHOP-rituximab for previously untreated diuse large B-cell lymphoma and mantle cell lymphoma. J Clin Oncol 2010; 29: 69097. Advani RH, Sharman JP, Smith SM, et al. The Btk inhibitor PCI-32765 is highly active and well tolerated in patients (pts) with relapsed/refractory B cell malignancies: nal results from a phase I study. Ann Oncol 2011; 22 (suppl 4): iv13537. Wilson WH, Dunleavy K, Pitaluga S, et al. Phase II study of dose-adjusted EPOCH and rituximab in untreated diuse large B-cell lymphoma with analysis of germinal center and post-germinal center biomarkers. J Clin Oncol 2008; 26: 271724.

Prevention of cervical cancer in womens hands: Mexico leads the way

In The Lancet,1 Eduardo Lazcano-Ponce and colleagues report the results of the rst community-based randomised trial to compare the eectiveness of HPV DNA testing of vaginal samples self-collected at home with clinician-collected cervical cytology, for detection of prevalent cervical intraepithelial neoplasia (CIN) grade 2 or greater. The trial randomly assigned 20 256 Mexican women aged between 25 and 65 years of low socioeconomic status to self-collection of samples for HPV testing (n=9202) or to clinicancollected cervical cytology (n=11 054). Women who were HPV positive or had cytological abnormalities (mild dysplasia or worse) were referred for diagnostic colposcopy and biopsies as needed. The detection rate of cytological abnormalities was 038% (95% CI 023045), which is lower than usually
www.thelancet.com Vol 378 November 26, 2011

reported.2 This nding indicates low-quality cytology and shows the challenge of using this technique in developing countries. Absence of inclusion of atypical squamous cells of undetermined signicance among the cytological abnormalities is unlikely to explain this low prevalence. That mild cytological lesions were almost completely undetected in the study is particularly noteworthy and explains the very high (905% [617100]) positive predictive value of cytology. By contrast, the detected HPV prevalence was roughly 10%, with a correspondingly low positive predictive value (122% [99145]), increasing with age as expected. HPV testing detected 34 times (2449) more prevalent CIN2 and greater, and 42 times (1992) more invasive cervical cancers than cytology, which clearly indicates that HPV testing of selfcollected vaginal specimens is better than cytology.

Published Online November 2, 2011 DOI:10.1016/S01406736(11)61101-X See Articles page 1868

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