Implementation status of cervical screening in Europe

Following the recommendation of the Council of the European Union, almost all governments made a policy statement on the introduction of cytology-based cervical screening for the health care system. However, the status of implementation is uneven. In the majority of the developed countries an organised model of screening recommended by the relevant international professional organisations are in use, while occasional screening is applied in some other countries. Screening strategies (i.e. age range, screening intervals), coverage of the target population, and compliance rates vary significantly. The screening activities are in a planning phase is some less developed Central-Eastern and South European countries. In Hungary, the transition from the traditional “gynaecological cancer screening” into the recommended organised cervical screening is in progress; the active involvement of the district health visitors in the cervical screening would provide further improvement. Orv. Hetil., 2014, 155(50), 1975–1988.

The status of cervical cytology in Swaziland, Southern Africa: a descriptive study

BACKGROUND

Cancer of the cervix is the most common cancer in women in Swaziland where most women never undergo cervical screening. The extremely high prevalence of HIV/AIDS in Swaziland complicates the management of preinvasive and invasive cervical cancer. The purpose of this study was to assess the current status of cervical cytology in Swaziland, its strengths and limitations.

METHODS

The study is a retrospective review of 12,188 conventional cervical smears received by the Central Public Health Laboratory in Swaziland from June 2004 to May 2006.

RESULTS

Review of results showed very high rates of cytologic abnormalities with 43.2% of smears screened reported as abnormal. The percentages of abnormalities were as follows: atypical squamous cells of undermined significance (ASC-US), 19.8%; atypical squamous cells, cannot exclude HSILs (ASC-H), 8.8%; low-grade squamous intraepithelial lesions (LSIL), 9.0%; high-grade squamous intraepithelial lesions (HSIL), 4.6%; squamous cell carcinomas, 0.5%; atypical endocervical cells, 0.6%; and atypical endometrial cells, 0.4%. Just over 5% of smears were inadequate. The highest rates of HSILs and invasive squamous carcinoma occurred in women aged 50-59 years.

CONCLUSIONS

This study underscores the need to reduce the incidence of cervical cancer and its precursor lesions in Swaziland women. Based on studies of human papillomavirus (HPV) types in other Southern African countries, current HPV vaccines would reduce the incidence and mortality from cervical cancer in the future, but cervical screening would still be required, both for women already infected with the HPV and for HPV subtypes not covered by current vaccines. The most cost-effective combination of screening modalities such as visual inspection, HPV DNA testing, and cytology should be investigated. Cervical cancer reduction needs to be managed within the greater framework of the HIV/AIDS epidemic.

Rapid rescreening of cervical smears as a quality control method in a high-risk population

OBJECTIVE

Cancer of the cervix is one of the commonest cancers in South Africa. Accurate cytological diagnosis is one of the prerequisites for an effective cervical screening programme and requires the implementation of appropriate quality assurance modalities. This study was undertaken to determine if rapid review of reportedly negative cervical smears is a useful internal quality assurance modality in an unscreened population with very high rates of cervical carcinoma.

METHOD

Approximately 26% of all cervical smears received at the study institution between 1 January 1998 and 31 December 2003, and initially reported as negative or inadequate, underwent rapid review.

RESULTS

A total of 62,866 (26%) cervical smears out of 241,796 reportedly negative or inadequate cervical smears underwent rapid review. An amended report was sent out in 373 (0.59%) of these 62,866 cervical smears. This included 101 cases of high-grade squamous intraepithelial lesion (HSIL) and high-grade atypical squamous cells (ASC-H), 143 low-grade squamous intraepithelial lesions, 54 atypical squamous cells of undetermined significance (ASC-US) and 33 atypical glandular cells that were not reported initially. The false-negative proportion for HSIL and ASC-H (combined) in this study was 5.76%. No squamous cell carcinomas were diagnosed on rapid review but one patient with HSIL/ASC-H on review had squamous cell carcinoma on biopsy. Three cytotechnologists had a lower sensitivity of primary screening and required retraining.

CONCLUSIONS

Rapid review is beneficial as an internal quality assurance modality in an unscreened high-risk population and increases the detection of women with significant cervical lesions requiring treatment. The relatively low cost of rapid review compared with other rescreening modalities makes this an attractive option in low resource settings.

Morphological analysis of squamous cells in routine Pap smears as a predictor of bone mineral density in asymptomatic women

OBJECTIVE

The present study attempted to find out possible coherence between morphologic characteristics in Pap smears and bone mineral density (BMD) as measured by DEXA.

STUDY DESIGN

DEXA measurement (with the result expressed as T-score) was performed in 79 women in whom Pap smears for routine cervical cancer screening were obtained. The smears were grouped into atrophic and mature cell patterns. Using astereological analysis, the mean areas of squamous cells, their nuclei and cytoplasm were estimated.

RESULTS

The mean areas of cells and cytoplasm were significantly lower at lower T-scores (P < 0.01), while the mean areas of nuclei were not (P > 0.5). T-scores were significantly lower in the atrophic cell pattern group (P < 0.001). The study group indicated concurrently high sensitivity of 80.9% and specificity of 78.1%, with positive predictive value of 84.4%.

CONCLUSION

These results suggest that a significant number of women with low BMD could be identified parallel with the routine Pap test for cervical cancer screening without additional costs.

Present standards for cervical cancer screening

Survival rates for cancer of the uterine cervix have improved over the last 40 years largely because of the impact of screening measures such as the Pap smear. The ability to screen and treat women for preinvasive disease, cervical dysplasia, is the key factor leading to the reduction in the incidence of invasive cervical cancer. More recently, the ability to test women for the causative agent, the human papilloma virus, has emerged as a potential screening tool. New research has focused on new technologies for Pap smear screening such as thin layer technology, the appropriate intervals for screening, and the appropriate methods of incorporation of human papilloma virus testing into the screening protocols. Reviews of published studies evaluating the efficacy of new technologies suggest that there is still insufficient information to confirm improved outcome; however, results to date suggest that thin layer Pap smear technology may improve sensitivity in the detection of cervical dysplasia. Automated rescreening technologies in use may decrease the number of false-negative Pap smears and are an option for laboratories. Various professional groups and countries have differing recommendations on the interval for screening, primarily on the basis of cost-effectiveness. Some of the most important new information this year regarding cervical cancer screening includes the new Bethesda System for the reporting of Pap smears and the new guidelines for the management of the abnormal Pap smear by the American Society of Colposcopy and Cervical Pathology. These guidelines incorporate human papilloma virus testing based on a multicenter trial documenting its efficacy in the triage of women with atypical squamous cells on Pap smear. These recommendations are reviewed along with the current literature on cervical cancer screening.