Cervical cancer control: a study of morbidity and mortality trends over a twenty-one-year period

Data from a 21-year period are presented to evaluate the effects of a mass cytologic screening program on uterine cancer morbidity and mortality in Louisville, Jefferson County, Kentucky. The success of screening was greatest in the younger age groups. There was a fall-off after age 45 years, especially in those age 60 years or older. Women at highest risk for cervical cancer, in the low socioeconomic quartile, had a better initial screening rate than the two middle-income quartiles, and had the highest rate of all women for subsequent rescreening. The greatest decrease in both morbidity and mortality was in women under the age of 50 years. Women age 30-39 and 50-59 years benefitted the most, as measured by mortality, with a decrease of 70.8 and 69.0%, respectively. There was no change in mortality rates for those age 70 years or older. Although the average annual age-adjusted rate increased from 13.2 to 15.3/100,000 women over the 21-year period.

[Impulse cytophotometry in neoplasm prevention. The behavior of normal vaginal smears in the impulse cytophotometric histogram]

Evaluation of histograms of normal cervical and vaginal smears, produced by ""rapid flow through'' cytophotometry. Normal cytological cervical and vaginal smears were examined for their appearance in histograms in order to find criteria for the classification of ""normal non-pathological'' cytological slides. Simultaneously, the reliability of the standardized method for preparation of vaginal and cervical smears was checked. The diagrams and data produced by the histograph were also coded on line and analyzed by a computer; thus obtaining an objective mathematical analysis and avoiding errors due to subjective visual analysis of the histograms. The objective interpretation of histograms of normal vaginal smears is an important step to the realisation of automatic pre-screening.

[The problem of ovarian cancer after preceding gynaecological operations. Case report with special reference to endometriosis (author's transl)]

5 cases of ovarian cancer following hysterectomy are presented. Prophylactic salpingo-oophorectomy is discussed. After age 45, a prophylactic salpingo-oophorectomy should be performed. After age 50, the ovaries should always be removed along with a hysterectomy. A case of ovarian adeno-carcinoma in the right parametrium two years following radical surgery for wide spread endometriosis is described in detail.

[Prevention of the malignant form of trophoblastic disease after a hydatidiform mole: systematic or selective chemotherapy]

After a mole has been evacuated there are two ways of treating the condition: routine chemotherapy from the beginning or chemotherapy reserved for selected cases. They offer the same chances of cure. Seeing that the risk of malignancy in our country is 5 per cent and that selective chemotherapy only exposes a small number of patients to the risk of such treatment, we have adopted the scheme of follow-up suggested by Bagshawe and recommended by OERTC. The follow-up is based on radio-immune assay for HCG carried out at regular intervals for two years. Only cases where the level of HCG is higher than 25,000 international units per litre, one month after curettage, or cases where the rise in HCG is associated with metastases, are treated with chemotherapy. In our experience, which is based on 20 cases, we acknowledge the value of radio-immune assaying. It is superior to immunological tests used for pregnancy diagnosis in sensitivity. It also appears to us that systematic treatment routinely administered and treatment based on raised levels of HCG two months after evacuation of a mole are useless. Only 3 cases were treated with chemotherapy out of the 20 cases that were followed up. We have had no malignancy after 2 and 3 years of checking back on the patients. Treatment given routinely from the start would have been unnecessary exposure to the risks of chemotherapy for 17 patients. Had we taken into account the abnormal rise in HCG after 8 weeks we would still have treated 7 patients instead of 3 with the same results as far as cure. We have worked out a graph for the drop in the levels of HCG after a mole has been evacuated. This may serve as a base for criteria for treatment in the future. Cases where the levels of HCG are above the 95 percentile are considered as at risk to evolve into malignant forms of disease. Consequently earlier treatment can be started (before the 6th month) without altering the number of patients who are going to be treated.

[The attitude of women to prophylactic hysterectomy (author's transl)]

The attitude of women to prophylactic hysterectomy (pH) after age 40 was investigated in 324 women in our out-patient clinic by a questionnaire taking into account psychological and sociological data. More than 50% of the women were against a prophylactic hysterectomy. This negative attitude cannot be explained by a desire for child bearing since only prophylactic hysterectomy after 40 was discussed. Other factors are important. The knowledge of the women about their reproductive organs was limited. One third of the patients thought the uterus is responsible for the production of sexual hormones and 3/4 of the women expected a hormonal imbalance following hysterectomy. The greater the ignorance the more frequent was the negative attitude to prophylactic hysterectomy (S 5%). 2/3 of the women ascribed a life long importance to the uterus and were against prophylactic hysterectomy (S 5%). 1/4 of the patients described the uterus as an organ important for sexual intercourse and therefore were against prophylactic hysterectomy (S 5%). It is understandable that 2/3 of the women thought of hysterectomy as a procedure which would have a negative or very negative influence on their lives (S 5%) when women ascribed to the uterus frequently a significance in hormone production or in sexuality in addition to the child bearing function of the uterus. Only approximately 1/3 of the women would feel of themselves as full women after a hysterectomy. Not quite 1/2 of the patients thought of the sterility following hysterectomy as a positive feeling and were more often accepting of the thought of a prophylactic hysterectomy (S 1%). Women who felt that they could talk about problems of their female genital organs with their partners had more often a negative attitude to prophylactic hysterectomy (S 1%). About 2/3 of the patients stated they would wish to have their partner present during a pre-operatitive discussion of a necessary hysterectomy. Only 1/4 of the patients were sure that a hysterectomy would not have a negative effect on their marital lives. Among the psychological factors, intelligence was of importance in the attitude to prophylactic hysterectomy. The more intelligent the woman, the more frequently she had a negative attitude to prophylactic hysterectomy (S 0.1%). There was no statistically significant correlation between personality factors according to Eysenck and the attitude to prophylactic hysterectomy. The older women more frequently accepted the thought of prophylactic hysterectomy (S 10%). The results were all tested statistically by the X2 method. A prophylactic hysterectomy should not be done without a thorough discussion of the attitudes and the expectational anxieties to such an operation.

[Is progesterone insufficiency carcihogenic?]

Estradiol is a natural estrogen which favors cellular hyperplasia at the level of its target organs. As for progesterone, its activity may be synergic or antagonist of estradiol. In the first case, progesterone has generally a secretory activity upon the target cells "prepared" by estrogens, in particular the cells of the female genital tract (uterus, breast). In the second case, progesterone may be an antiestrogen not only at the level of genital cells but also at the level of other receptors such as vascular system, etc. If an unbalance occurs in the quantitative and chronological ratio between estradiol and progesterone production (which determines the number of target cells and their secretory activity), a cellular dysplasia may be observed. This unbalance is generally characterized by an insufficiency in progesterone secretion which may be physiological (puberty, menopause) or pathological. Such a progesterone insufficiency may play a role in the pathogenesis of genital cancers (endometrial and possibly mammary). Experimental data which give some support to such an hypothesis are reported. They emphasize the importance of treatment of the progesterone insufficiency of the premenopausal period in women with the aim of preventing cellular dysplasia of the female genital tract.

[Notes on cases of carcinoma of the uterine body observed in the S. Anna Hospital, Turin, between 1954-1969 and the Piedmont and Aosta Valley areas in the period 1965-1969]

An increase in the frequency of corpus cancer over the period 1954-1969 and 1965-1969 in records for the S. Anna Hospital, Turin, and the Piedmont and Aosta Valley areas respectively is reported. Attention is drawn to the fact that more than 30% of patients were in the 66-80 age group (i.e. over the usual age of 56 to 60). A higher frequency of infertility and delayed menopause in patients with such tumours has been proved statistically significant. Diabetes, obesity and hypertension are pathogenetically linked to adenocarcinoma of the endometrium and not to casual associations. The findings are in line with the view that this neoplasia is hormone-dependent and a public health programme for its prevention is proposed.