Effect of organized screening on the risk of cervical cancer. Evaluation of screening activity in Iceland, 1964-1991

Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana

Background

The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana.

Methods

This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI).

Results

Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone.  Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit.

Discussion

In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.

Normas e Recomendações do Instituto Nacional de Câncer/MS

Recomendações Básicas para o Controle do Câncer do Cólo do Utero no Brasil.

Programa de detecção do câncer do colo uterino de Campinas e Região: 1968-1996

O Programa de Controle do Câncer do Colo Uterino (PCCCU) de Campinas e região foi iniciado em 1968, por iniciativa do Departamento de Tocoginecologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, integrando a Universidade com as unidades da rede básica de saúde. O Programa foi expandido para 47 municípios da região e conta com vários centros de complexidade secundária e terciária, que servem de referência para o PCCCU. Com base nos dados do Laboratório de Citopatologia do Centro de Atenção Integral à Saúde da Mulher da Universidade Estadual de Campinas, foi estimada a cobertura do Programa em 1996. Os resultados mostraram que a cobertura foi maior que 20% em 21% dos municípios, maior que 15% em 53% dos municípios e menor que 10% em 15% dos municípios. Concluímos que a cobertura está baixa na quase totalidade dos municípios. Como os dados disponíveis referem-se apenas aos serviços públicos, a cobertura real deve ser maior devido a participação dos serviços privados, que em alguns municípios chegam a atender cerca de 50% da população.

Adherence to international recommendations in the governance and organisation of Nordic cervical cancer screening programmes

INTRODUCTION

Screening has been the primary reason for the decline in the incidence and mortality of cervical cancer in the Nordic countries since the beginning of screening in the 1960s. Recently, the incidence of cervical cancer has increased in the Nordic countries indicating the need to look closely at possibilities for further improvement in screening. This article provides an overview of cervical cancer screening programmes in the Nordic countries and whether the programmes adhere to international recommendations.

MATERIALS AND METHODS

Relevant and unambiguous screening recommendations were extracted from applicable literature and classified into legal framework, governance, organisation, and monitoring and evaluation. The up-to-date status of screening programmes and adherence to selected recommendations was gathered from official documentation and co-authors representing cervical cancer screening programmes in all the Nordic countries.

RESULTS

A total of 168 recommendations were extracted and 54 of them were considered to be unambiguous and relevant. Forty-nine recommendations were included after synthesising similar recommendations. All Nordic countries adhere to recommendations related to legal framework, but adherence was lower with recommendations related to governance and organisation of screening. Monitoring and evaluation are also areas where adherence to recommendations could be improved.

CONCLUSIONS

The Nordic cervical cancer screening programmes have substantially decreased cancer burden despite not fully adhering to many of the recommendations. The presented gaps in adherence suggest that there is room for improvement in the screening programmes. Establishing clearer governance structures would still increase the ability to manage changes such as implementing HPV testing as the primary screening method or modifying the programme when HPV vaccinated cohorts of women enter the target age for screening.

Benefit of double-reading cytology smears as a triage strategy among high-risk human papillomavirus-positive women in Mexico

BACKGROUND

The goal of this study was to determine whether the detection of histologically confirmed cases of cervical high-grade squamous intraepithelial lesions or worse (HSIL+) can be increased by having each liquid-based cytology (LBC) slide read by 2 cytotechnologists as part of routine screening.

METHODS

Over 36,212 women aged 30 to 64 years participated in the Forwarding Research for Improved Detection and Access for Cervical Cancer Screening and Triage (FRIDA) Study in Mexico between 2013 and 2016. For each participant, 2 cervical samples were collected at the same clinic visit, one to test for high-risk human papillomavirus (hrHPV) and the other for LBC, which was used to triage those with a hrHPV positive result. LBC slides were evaluated by 7 cytotechnologists, with each slide read independently by 2 blinded cytotechnologists. All women with atypical cells of undetermined significance or a worse result were referred to colposcopy for further evaluation and diagnosis. Three pathologists evaluated the biopsy specimens to confirm the final HSIL+ diagnosis. The HSIL+ detection rates for the single versus double reading were estimated and compared.

RESULTS

A total of 3,914 women with a positive hrHPV result were triaged with LBC. The first and second cytology readings resulted in 43 HSIL+ cases detected; the double-reading strategy detected 9 additional HSIL+ cases, resulting in a total of 52 HSIL+ cases. The HSIL+ detection rate increased from 10.99/1000 with a single reading to 13.29/1000 with the double-reading strategy (P = .004).

CONCLUSION

A 20.9% increase in HSIL+ cases detected was achieved with a double reading of the LBC slides in this sample of hrHPV-positive women.

Age-related acceptability of vaginal self-sampling in cervical cancer screening at two university hospitals: a pilot cross-sectional study

BACKGROUND

To determine whether age is a barrier against acceptability of cervicovaginal self-sampling in screening for cervical cancer at two gynecology outpatient clinics.

METHODS

This is a cross-sectional study involving 116 women over 21 years of age with an abnormal Pap smear. Clinical and laboratorial data were recorded in electronic files. Women received detailed self-collection instructions. After the self-sampling procedure (Evalyn Brush®), women were instructed to answer a questionnaire about vaginal self-sampling acceptability that consisted of seven multiple-choice items. The participants were divided into three age brackets: 21 to 29 years, 30 to 49 years, and 50 years and over. Chi-square, Fischer exact, Kolmogorov-Smirnov and Kruskal-Wallis tests were used.

RESULTS

The analysis of the participants' perception of the procedure stratified according to age groups showed a decline in the fear of hurting oneself during the procedure as age increased. Most participants reported that it was very easy to understand how to use the self-sampling brush and that it was easy to use it. Most of them were neither embarrassed nor afraid of getting hurt during the procedure. The majority preferred self-sampling to collection by a healthcare professional. The main reason was practicality: the possibility of choosing the place and time for sampling.

CONCLUSIONS

The participating women found self-collection simple to understand and easy to accept regardless of age. The younger women indicated more fear and discomfort in self-sampling, which points to the need for attraction strategies that are more appealing to the younger generations.

Organization and first results of cervical cancer screening program in Mayotte, from 2010 to 2014

OBJECTIVES

Our main goal was to report the organization of individual screening for uterus cancer in Mayotte, the last French department since 2011, and its first results.

MATERIAL AND METHODS

Epidemiological and observational study describing the prior situation, the beginning of the screening with pap smears in 2010, the colposcopy consultations and the treatment of the patients by the Mayotte network for screening of cancers since 2010.

RESULTS

The screening allowed an improvement of the global cover rate from 5% to 24% in 5 years. The best results concern the woman from 25 to 39 years old, with a rate that rose from 14 to 46%.

CONCLUSION

This study confirms the possibility and the efficiency of a screening program on this island, which is French by law, by much closer to developing countries on many other sides.

The utilization and barriers of Pap smear among women with visual impairment

Background

Many evidences illustrate that the Pap smear screening successfully reduces if the cervical cancer could be detected and treated sufficiently early. People with disability were higher comorbidity prevalence, and less likely to use preventive health care and health promotion activities. There were also to demonstrate that people with visual impairment has less access to appropriate healthcare services and is less likely to receive screening examinations. In Taiwan, there was no study to explore utilization of Pap smear, associated factors and use barriers about Pap smear screening test among women with visual impairment.

The purpose is to explore the utilization and barriers of using Pap smear for women with visual impairment in Taiwan. To identify the barriers of women with visual from process of receiving Pap smear screening test.

Methods

The cross-sectional study was conducted and the totally 316 participators were selected by stratified proportional and random sampling from 15 to 64 year old women with visual impairment who lived in Taipei County during December 2009 to January 2010. The data was been collected by phone interview and the interviewers were well trained before interview.

Results

The mean age was 47.1 years old and the highest percentage of disabled severity was mile (40.2 %). Totally, 66.5 % of participators were ever using Pap smear and 38.9 % used it during pass 1 year. Their first time to accept Pap smear was 38.8 year old. There was near 50 % of them not to be explained by professionals before accepting the Pap smear. For non-using cases, the top two percentage of barriers were “feel still younger” (22.3 %), the second was “there’s no sexual experience” (21.4 %). We found the gynecology experiences was key factor for women with visual impairment to use Pap smear, especially the experiences was during 1 year (OR = 4).

Conclusions

Associated factors and barriers to receive Pap smear screening test for women with visual impairment can be addressed through interventions aimed at improving on cognitions and attitudes for cervical cancer risk factors. Our study would be as a reference resource for erasing the barriers and inequality among the visually disabled women.

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

When Life Got in the Way: How Danish and Norwegian Immigrant Women in Sweden Reason about Cervical Screening and Why They Postpone Attendance

Introduction

Danish and Norwegian immigrant women in Sweden have an increased risk of cervical cancer compared to Swedish-born women. In addition, Danish and Norwegian immigrant women follow the national recommendations for attendance at cervical screening to much lesser extent than Swedish-born women. The aim of this study was to explore how Danish and Norwegian immigrant women in Sweden reason about attending cervical screening, focusing on women’s perceptions as to why they and their compatriots do not attend.

Methods

Eight focus group discussions (FGDs) were conducted with Danish and Norwegian immigrant women living in Stockholm. The women were between 26 and 66 years of age at the time of the FGDs, and were aged between <1 and 48 years old when they immigrated to Sweden. A FGD guide was used, which included questions related to cervical screening, and obstacles and motivators to attend cervical screening. The FGDs were tape recorded and transcribed, and the results analysed according to the principles of qualitative content analysis.

Results

The main theme was “Women have a comprehensive rationale for postponing cervical screening, yet do not view themselves as non-attenders”. Investigation of women’s rationale for non-attendance after being invited to cervical screening revealed some complex reasons related to immigration itself, including competing needs, organisational and structural factors and differences in mentality, but also reasons stemming from other factors. Postponing attendance at cervical screening was the category that linked all these factors as the reasons to why women did not attend to cervical screening according to the recommendations of the authorities.

Conclusions

The rationale used to postpone cervical screening, in combination with the fact that women do not consider themselves to be non-attenders, indicates that they have not actively taken a stance against cervical screening, and reveals an opportunity to motivate these women to attend.

Cervical cancer screening and follow-up in 4 geographically diverse US health care systems, 1998 through 2007

BACKGROUND

Cervical cancer screening and follow-up guidelines have changed considerably in recent years, but to the authors' knowledge few published reports exist to estimate the impact of these changes in community-based settings. The authors examined the patterns and results of cervical cancer testing and follow-up over a decade in 4 geographically diverse US health care systems to inform the future evaluation of changes resulting from increased uptake of the human papillomavirus (HPV) vaccination.

METHODS

The authors studied women aged 21 to 65 years who were members of one of these health systems at any time between 1998 and 2007. Data were collected and standardized across sites, based on receipt of Papanicolaou (Pap) and HPV tests, HPV vaccination, cervical biopsies, and treatment of cervical dysplasia. Annual rates (per 1000 person-years) of Pap testing, HPV testing, and cervical biopsy and treatment procedures were calculated. Screening intervals and trends in the results of screening Pap tests and cervical biopsies also were examined.

RESULTS

Pap testing rates decreased (from 483 per 1000 person-years in 2000 to 412 per 1000 person-years in 2007) and HPV testing rates increased over the study period. Screening frequency varied across health care systems, and many women continued to receive annual testing. All 4 sites moved to less frequent screening over the study period without marked changes in the overall use of cervical biopsy or treatment.

CONCLUSIONS

Despite differences over time and across health plans in rates of cervical cancer testing and follow-up cervical procedures, the authors found no notable differences in Pap test results, diagnostic or treatment procedure rates, or pathological outcomes. This finding suggests that the longer screening intervals did not lead to more procedures or more cancer diagnoses.

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.

'Organised' cervical screening 45 years on: How consistent are organised screening practices?

Organised screening programmes have been remarkably successful in reducing incidence and mortality from cervical cancer, while opportunistic screening varies in its effectiveness. Experts recommend that cervical screening or HPV testing be carried out only in the context of an organised programme. We sought to answer the following study questions: What does it mean for a cervical screening programme to be organised? Is there a place for opportunistic screening (in an organised programme)? We reviewed 154 peer-reviewed papers on organised and opportunistic approaches to cervical screening published between 1970 and 2014 to understand how the term 'organised' is used, formally and in practice. We found that despite broad recognition of a prescriptive definition of organisation, in practice the meaning of organisation is much less clear. Our review revealed descriptions of organised programmes that differ significantly from prescribed norms and from each other, and a variety of ways that opportunistic and organised programmes intersect. We describe the breadth of the variation in cervical cancer screening programmes and examine the relationships and overlaps between organised and opportunistic screening. Implications emerging from the review include the need to better understand the breadth of organisation in practice, the drivers and impacts of opportunistic screening and the impact of opportunistic screening on population programme outcomes. Appreciation of the complexity of cervical screening programmes will benefit both screeners and women as programmes are changed to reflect a partially vaccinated population, new evidence and new technologies.

Increased exosomal microRNA-21 and microRNA-146a levels in the cervicovaginal lavage specimens of patients with cervical cancer

Well-run screening programs for cervical cancer in the population at risk have been shown to result in a sharp decrease in the incidence and mortality of cervical cancer in a number of large populations. Expression patterns of a recently identified biomarker family, microRNA, appear to be characteristic of tumor type and developmental origin. Several tumors have been reported to actively release exosomes carrying microRNAs. The present study has determined the association of microRNAs with cervical cancer-derived exosomes. The cervical cancer-derived exosomes were enriched in the cervicovaginal lavages specimens and the abundance of exosomes and exosomal microRNAs was detected by electron microscopy, western blot analysis, RT-qPCR and microRNA target reporter vector. The microRNA-21 and microRNA-146a, which were up-regulated in cervical cancer patients, were associated with the high levels of cervical cancer-derived exosomes. In conclusion, we demonstrated the abundance of exosomes in the cervicovaginal lavage specimens of women with cervical cancer. Furthermore, our results indicated that abnormally high levels of microRNA-21 and microRNA-146a existed in the cervical cancer-derived exosomes and the two microRNAs were functional in 293T cells.

Exploring colposcopists' attitudes towards use of HPV testing as a primary screening tool for cervical cancer in British Columbia

OBJECTIVE

To examine colposcopists' attitudes regarding human papillomavirus (HPV) DNA testing as a primary screening tool for cervical cancer.

METHODS

Questionnaires administered in 2010 and 2011 during workshops in British Columbia elicited colposcopists' attitudes using a series of five-point Likert-style scales (strongly disagree to strongly agree) and binary (yes/no) response questions. The frequency of "agree" or "strongly agree" was used to characterize attitudes. Regression analyses examined statistically significant changes in attitudes after the 2010 workshop.

RESULTS

Responses generally indicated positive changes in attitudes toward HPV testing. Statistically significant changes after the 2010 workshop were observed for the items relating to strong agreement that HPV is a necessary cause of cervical cancer (39% increase; P < 0.001) and the likelihood of openly advocating for HPV testing (19% increase; P < 0.04). In 2010, 40% of colposcopists stated that four years between HPV tests is too long, and in 2011, 53% did so.

CONCLUSION

Colposcopists are viewed as opinion leaders and will have a critical role in implementing HPV testing in BC; our study obtained responses from 73% (2010) and 84% (2011) of BC-registered colposcopists. Colposcopists were in favour of HPV testing for primary screening for cervical cancer but did not support an extended interval for HPV testing, which suggests future knowledge translation workshops are crucial. We found that knowledge translation workshops can be an effective approach for translating evidence on screening and screening practices.

The evolution of the Papanicolaou smear

The Papanicolaou smear or cervicovaginal cytology has been the mainstay of screening for cervical cancer in women of over 60 years. In this article, the origins of the Pap smear as a screening method and the many changes associated with the use of the Pap smear are detailed.

Efficacy of screening in preventing cervical cancer among older women

BACKGROUND

Although the effectiveness of cervical cancer screening has been firmly established in reproductive-age women, its usefulness in older women is unclear. We sought to evaluate the efficacy of cervical cancer screening in older women.

METHODS

We conducted a case-control study within two integrated health care systems in the northwestern United States. Cases (n = 69) were women aged 55-79 years who were diagnosed with invasive cervical cancer during 1980-1999. Controls (n = 208) were women with an intact uterus and no diagnosis of cervical cancer, but otherwise similar to cases in terms of age and length of enrollment in the health plan. We reviewed medical records to ascertain screening history during the 7 years prior to reference date.

RESULTS

Compared to cases, controls were more likely to have received a Pap test. After adjustment for age and current smoking status, screening prior to an estimated 1-year duration of the occult invasive phase of cervical cancer was associated with a substantial reduction in risk [odds ratio (OR) 0.23; 95% CI 0.11-0.44]. Similar results were obtained using different estimates of the duration of the occult invasive phase. Analysis of the relative incidence of invasive cervical cancer in relation to the time following a negative screening test suggested a large reduction during the first year (OR 0.09; 95% CI 0.03-0.24). The incidence remained low for several years thereafter, returning to the incidence among unscreened women after 5-7 years.

CONCLUSIONS

Cervical cancer screening by means of cytology is highly efficacious in older women. Our findings also suggest that five-yearly screening is approximately as efficacious as more frequent screening.

Screening for Cervical Cancer in Low-Resource Settings in 2011

Context.—Cervical cancer remains the most common malignancy in women living in low- and middle-income countries, despite the decline of the disease in countries where cervical cytology screening programs have been implemented.

Objectives.—To review the current incidence of cervical cancer in low-resource countries, the availability and types of screening programs, and the treatment options.

Data Sources.—Literature review through PubMed, Internet search, and personal communication.

Conclusions.—Although data are incomplete, available figures confirm that the rate of cervical cancer deaths and the availability of cervical cancer screening programs are inversely proportional and vary, in general, by the wealth of the nation. Despite the success of cervical cytology screening, many major health care organizations have abandoned screening by cytology in favor of direct visualization methods with immediate treatment of lesions by cryotherapy provided by trained, nonmedical personnel.

Evidence for cervical cancer mortality with screening program in Taiwan, 1981-2010: age-period-cohort model

Background

Cervical cancer is the most common cancer experienced by women worldwide; however, screening techniques are very effective for reducing the risk of death. The national cervical cancer screening program was implemented in Taiwan in 1995. The objective of this study was to examine and provide evidence of the cervical cancer mortality trends for the periods before and after the screening program was implemented.

Methods

Data from 1981 to 2010 of the causes of death registered were obtained from the Department of Health, Taiwan. Age-standardized mortality rates, age-specific rates, and age-period-cohort models that employed the sequential method were used to assess temporal changes that occurred between 1981 and 2010, with 1995 used as the separating year.

Results

The results showed that for both time periods of 1981 to 1995 and 1996 to 2010, age and period had significant effects, whereas the birth cohort effects were insignificant. For patients between 80 and 84 years of age, the mortality rate for 1981 to 1995 and 1996 to 2010 was 48.34 and 68.08. The cervical cancer mortality rate for 1996 to 2010 was 1.0 for patients between 75 and 79 years of age and 1.4 for patients between 80 and 84 years of age compared to that for 1981 to 1995. Regarding the period effect, the mortality trend decreased 2-fold from 1996 to 2010.

Conclusions

The results of this study indicate a decline in cervical cancer mortality trends after the screening program involving Papanicolaou tests was implemented in 1995. However, the positive effects of the screening program were not observed in elderly women because of treatment delays during the initial implementation of the screening program.

Intramuscular metastatic squamous cell carcinoma of the cervix: autopsy case report

Cancer of the uterine cervix is the fourth leading cause of death in women in Brazil, accounting for 4800 fatal cases per year. The histology of this neoplasia is mainly represented by squamous cell carcinoma (80-85%), adenocarcinomas (10-15%), and, more rarely, mixed carcinomas. The Papanicolaou (Pap) smear test is the method of excellence in detecting incipient or pre-malignant lesions. Since its implementation, the Pap test has been reducing the incidence of this neoplasia worldwide, despite its lack of high sensitivity and specificity. Both incidence and mortality from cervical cancer have sharply decreased following the introduction of well-run screening programs. The cervical cancer typically spreads to adjacent structures by contiguity; pelvic and para-aortic lymph nodes are involved by lymphatic dissemination. Less frequently, hematogenic spread is observed, and when it occurs, the brain, breast, and skeletal muscle are rarely involved. The authors report a case of a young woman who underwent periodical gynecological examination with negative Pap tests and presented to the hospital with an advanced cervical metastatic disease involving thyroid, muscles, lymph nodes, and breast (among others sites). The diagnosis of the primary site was not elucidated during life. The patient died, and at autopsy an endophytic squamous cell carcinoma of the cervix was diagnosed.

'Omic approaches to preventing or managing metastatic breast cancer

Early detection of metastasis-prone breast cancers and characterization of residual metastatic cancers are important in efforts to improve management of breast cancer. Applications of genome-scale molecular analysis technologies are making these complementary approaches possible by revealing molecular features uniquely associated with metastatic disease. Assays that reveal these molecular features will facilitate development of anatomic, histological and blood-based strategies that may enable detection prior to metastatic spread. Knowledge of these features also will guide development of therapeutic strategies that can be applied when metastatic disease burden is low, thereby increasing the probability of a curative response.

Imaging of endometrial and cervical cancer

In this article we review the ever increasing role of imaging in endometrial and cervical cancer. Magnetic resonance imaging (MRI) has emerged as the most widely used technique in the management of women with gynaecological cancer. In endometrial cancer, MRI is reliable in identifying myometrial and cervical invasion and extra-uterine disease, thereby informing preoperative surgical planning. In cervical cancer, MRI plays a crucial role in distinguishing early from advanced disease, thereby stratifying patients for surgery and chemoradiation. MRI is also valuable in assessing proximal extension of cervical tumours in young women with early stage disease for feasibility of fertility preserving surgery. In both cancers, imaging is used for diagnosing nodal metastases, detection of recurrence, and dealing with complications of both the disease and treatment.

MRI and PET scans for primary staging and detection of cervical cancer recurrence

Worldwide, cervical cancer is the second most common malignancy in women, and is a major cause of morbidity and mortality. Accurate tumor staging is essential for optimal treatment planning and prognosis. Cervical cancer is staged by clinical examination according to the International Federation of Gynecology and Obstetrics staging system. However, clinical staging has inherent deficiencies in evaluating several parameters that are critical for treatment planning. It is now widely accepted that cross-sectional imaging, and in particular MRI, has an important role to play in the staging of these tumors. MRI is an excellent modality for depicting invasive cervical cancer: it can provide objective measurement of tumor size and provides a high negative predictive value for parametrial invasion and stage IVA disease. MRI and positron emission tomography (PET)/computed tomography (CT) play key roles in identifying recurrent disease. PET/CT is also useful in detecting nodal and distant metastases and in radiotherapy planning. Diffusion-weighted MRI is an emerging imaging technique that is currently being evaluated for the detection of primary and recurrent disease and in the assessment of treatment response.

Reasons for non-attendance at cervical screening as reported by non-attendees in Sweden

PURPOSE

To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden.

METHODS

Four hundred women were randomized from a population-based register, of which 133 non-attendees answered the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson's Chi2 and Mann-Whitney U-test were used to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables and a binary response variable.

RESULTS

The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of discomfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of discomfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those who had.

CONCLUSION

It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to guide their decision not to attend.

Promotion of cervical screening among nonattendees: a partial cost-effectiveness analysis

Measures to increase attendance rate in cervical screening programmes have been suggested, but few have been evaluated in terms of value for money. The aim of this study was to describe the cost-effectiveness of a resource-intensive intervention to promote attendance at cervical screening among women with no registered cervical smear during the last 5 years. Among all 56 644 women (28-65 years) in Kalmar County, January 2004, a total of 6565 women had no registered cervical smear during the last 5 years. From this population, 400 women were randomly selected to a study group and another 400 women to a control group. The intervention was composed of a variety of efforts intended to promote attendance at cervical screening. We included, for example, all costs for identifying the women, sending out invitation letters, making phone calls and helping to make arrangements. Data on registered cervical smears at follow-up were collected from a data register within 1 year. In the study group, 118 women had a registered cervical smear compared with 74 in the control group (P=0.000). In the study group, the cost per cervical smear taken was 66.87 euro compared with 16.63 euro in the ordinary screening programme. The incremental cost per additional registered cervical smear was calculated at 151.36 euro in an area with high coverage, efforts to promote attendance at cervical screening were related to high costs per extra cervical smear gained and is not considered as reasonable from a cost-effectiveness perspective.

Acceptability of reminder letters for Papanicolaou tests: a survey of women from 23 Family Health Networks in Ontario

OBJECTIVE

To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations.

METHODS

A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents.

RESULTS

The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures.

CONCLUSIONS

Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Self-efficacy scale for Pap smear screening participation in sheltered women

BACKGROUND

Sheltered, homeless women disproportionately experience cervical dysplasia and cervical cancer. Low rates of Pap smear screening contribute to late diagnosis with accompanying increased morbidity and mortality. Self-efficacy (SE) has been demonstrated to be predictive of several health behaviors, but limited evidence about SE for Pap smear screening exists.

OBJECTIVES

To develop, test, and refine the conceptually based Self-Efficacy Scale for Pap Smear Screening Participation (SES-PSSP).

METHODS

This correlational, descriptive study included a purposive sampling of sheltered women (N = 161).

RESULTS

The 20-item SES-PSSP demonstrated acceptable initial validity and reliability. Reliability estimates of stability (>or=84%) and internal consistency (alpha = .95) exceeded criteria. Content validity and construct validity were supported (e.g., common factor analysis and predictive model testing that included SE, decisional balance, knowledge regarding Pap smear screening, demographics, health-related behaviors, health status, and personal beliefs about risks for cervical cancer and dysplasia). Self-efficacy, decisional balance, illicit drug usage, and age predicted 28% of the variance in stages of change (precontemplation, contemplation, preparation, action, and maintenance) for Pap smear screening participation.

DISCUSSION

The SES-PSSP provides a new scale for measuring SE pertinent to Pap smear screening participation in a vulnerable, ethnically diverse sample of sheltered, inner-city women. Validity testing demonstrated that the SE concept was predictive of Pap smear screening behavior, suggesting that SE-based interventions tailored to the SES-PSSP subscale or total scores could increase screening. A 10-minute completion time supports feasibility for use in the clinic setting.

Systematic review of baseline low-dose CT lung cancer screening

The purpose of this systematic review was to provide physicians and patients with a synthesis of the available data and an assessment of the operating characteristics associated with baseline LDCT screening for lung cancer. Various databases, meeting abstracts, clinical trials in progress, and major textbooks for relevant data from 1966 to 2006 were searched for relevant studies. The median value of sensitivity, specificity, positive predictive value and negative predictive value were 81%, 81%, 8% and 99%, respectively. Of the studies that compared LDCT with other lung cancer screening maneuvers, it was found that LDCT detected a greater number of cancerous nodules. On average, 80% of lung cancers detected by baseline LDCT screening were categorized as Stage I cancers. Current data demonstrate that both the operating characteristics of baseline LDCT screening and the relatively high proportion of Stage I cancers detected with LDCT may potentially lead to effective screening programs. However, evidence of reduced mortality and morbidity with the use of LDCT is not established. Therefore, LDCT for lung cancer screening should be considered as investigative and needs to be confirmed by well-designed randomized controlled trials prior to community and institutional implementation.

Evaluation of a combined screening programme for breast, cervical and colorectal cancers in France

A combined breast, cervical and colorectal cancer screening programme was set up in 1990 in Isère, for women aged 50-69 years (target population 100,000) comprising an initial medical visit. The programme was evaluated in 1997. The evaluation covered uptake results, sensitivity, specificity, two opinion surveys among 1025 physicians and 400 women to measure the impact, and three surveys regarding radiologists', gastroenterologists' and pathologists' attitudes. Sensitivity and specificity rates were 74 and 87% for breast, 83 and 99% for cervical and 43 and 97% for colorectal screening. The number of cervical smears completed by women aged 60-69 years doubled with the programme. Acceptability of the faecal occult blood test was 88%. Eighty percent of physicians were in favour of the programme but 67% said that they often prescribed outside the programme. Overall, 71% of the interviewed women said they had had a breast screen, 69% a Pap smear and 53% a faecal occult blood test when only 25-35% of the target population was actually recorded in the programme. This programme increased the uptake of women not previously screened both within and outside the programme. It showed discrepancies between beliefs and practices of physicians. Protocol changes were implemented after this evaluation.

Is it rational to start population-based cervical cancer screening at or soon after age 20? Analysis of time trends in preinvasive and invasive diseases

The effect of starting screening at age 20 in 1988 was assessed by analysing (a) the age-specific incidence and distribution of stage and histology of invasive diseases, and (b) the detection rates of histologic moderate to high-grade intraepithelial neoplasia (CIN 2-3/AIS), and 1st abnormal cytology and repeat low-grade cytology after follow-up observation. Cancer incidence increased significantly at age 25-34 after 1979 due to early stage squamous cell and adenocarcinoma. After an initial increased rate of preinvasive disease, CIN 3 decreased significantly at age 30-34 after 1988, at age 25-29 after 1993, and levelled out after 1998 at age 20-24. The rates of CIN 2 levelled out after 1998. The rates of repeat low-grade smears decreased after observation at age 20-24 by 80%. The study confirms an increasing rate of preinvasive and invasive disease among younger women and indicates the benefit of starting organised screening at 2-3 year intervals soon after age 20.

Effectiveness of cervical cancer screening over cervical cancer mortality among Japanese women

BACKGROUND

Various studies have revealed that cervical cancer (CC) screening significantly reduces both CC incidence and mortality in developed countries. Although Japan introduced a nationwide government funded annual CC screening for the women aged 30+ in 1982, the effectiveness of CC screening on CC mortality has not yet been evaluated by any prospective cohort study. Therefore, the present study evaluated the association of CC mortality with self-reported CC screening and some other factors by a nationwide cohort study.

METHODS

Baseline survey of the Japan Collaborative Cohort Study for the enrollment of subjects was completed during 1988-90 and followed until 2003. This study only analyzed 63,541 women, aged 30-79 years, who were free from any cancer history at enrollment.

RESULTS

During the follow-up period, 38 CC deaths were identified. The mean age at mortality was 67.0 years, with a mortality rate of 4.2 per 100,000 person-years. Participation rate in CC screening was 46.9%. Age-adjusted Cox model indicated significantly lower CC mortality [hazard ratio (HR) = 0.30, 95% confidence interval (CI) = 0.12-0.74] due to CC screening. Protectiveness remained almost the same (HR = 0.30, 95% CI = 0.12-0.76) when adjusted for age, body mass index and number of deliveries. The results also revealed that CC screening could reduce at least 50% of CC deaths even after excluding the effect of possible self-selection bias.

CONCLUSIONS

CC screening in Japan may reduce CC mortality significantly for women aged 30-79 years. However, further studies with more CC deaths and increased statistical power are needed to validate the findings.

Cervical cancer incidence and mortality in the best and worst of worlds

BACKGROUND

Globally speaking, cervical cancer is a common cause of death. The cancer is caused by a human papillomavirus (HPV) infection, and hence is preventable. Pap smear screening allows for the early detection of precancerous lesions that are easily treated in a pre-invasive phase of the disease. New tests and treatment methods have the overall aim of lowering cervix cancer incidence and death. However, whether a woman will or will not develop cervix cancer depends on a complex number of interacting variables.

AIM

The aim of the present study was to identify factors that might have an impact on cervix cancer incidence and mortality, and rank them according to the weight of their relative influence.

METHODS

By using a forecasting model called the scenario method, factors were identified that could have an impact on cervix cancer development, and their relative importance was ranked by using a special matrix. The figures given for each factor were summed and presented in a System Grid, which made it possible to determine the most important variable.

RESULTS

The cultural structure of the female population, as well as women's habits and behaviour, all seem to be more important factors than the Pap smear test or the treatment in relation to cervical cancer incidence and mortality.

CONCLUSION

In the endeavour to prevent cervical cancer one must consider the whole chain of events, i.e. population-tests-treatment-outcome. New and improved test methods and treatment procedures are of little use if women refrain from coming for a test when called.

Is there a correlation between vaginal chlamydia infection and cervical smear abnormalities? A community-based study in the Al-Ain district, United Arab Emirates

AIM

The purpose of this study was to determine the correlation between vaginal chlamydia infection and cervical abnormalities. The data on the prevalence of chlamydia infection and cervical abnormalities have been presented elsewhere and in this article we provide the results of a correlation analysis.

METHODS

In this cross-sectional, community-based survey, women attending primary and secondary care in the Al-Ain medical district, United Arab Emirates, were offered cervical screening using the Papanicolaou smear, and chlamydia testing. A total of 793 women underwent cervical screening and 728 were tested for chlamydia. A commercially available kit was used to determine the prevalence of chlamydia. The correlation between cervical abnormalities and chlamydia infection was tested using the chi-squared test or Fisher's exact test, as appropriate.

RESULTS

The prevalence of abnormal smears was 1.51% (95% confidence interval [CI], 0.66-2.4). Twelve subjects had abnormal smears, including smears showing atypical squamous cells of undetermined significance. The prevalence of chlamydia infection in this population was 2.5% (95% CI, 1.2-3.3). Statistical analysis showed no association (chi2 0.6, P = 0.4) between the prevalence of chlamydia infection and cervical abnormalities.

CONCLUSION

Although there have been earlier reports of an association between vaginal chlamydia and cervical abnormalities, our study does not provide evidence to support this association.

Decline in Cervical Cancer Incidence and Mortality in New South Wales in Relation to Control Activities (Australia)

BACKGROUND

To examine time trends in cervical cancer incidence and mortality in NSW women aged yen20 years in relation to important health service initiatives and programs.

METHODS

Data on cervical cancer incidence and mortality were obtained from the NSW Central Cancer Registry for 1972-2001, and corresponding annual populations obtained from the Australian Bureau of Statistics. Direct age-standardised rates in the yen20 year population were calculated using the 2001 NSW census population as standard. Proportional reductions in incidence and mortality since 1972-1974 were also calculated and related to key health service factors and to published NSW 5-year cervical cancer relative survival for similar periods.

RESULTS

Declines in cervical cancer incidence (-10%) and mortality (-20%), and increased degree-of-spread specific survival following the introduction of universal health care in 1975 suggest effects of greater access to Pap screening, earlier access to diagnosis and treatment services, and improved effectiveness of treatment. Incidence plateaued during the 1980s, but mortality fell further (-7%) due to an increased proportion of localised cancers (without change to degree-of-spread specific survival). The 1980s mortality reduction was a consequence of earlier diagnosis and/or secondary prevention, not improved treatment effectiveness or reduced incidence. A marked and sustained incidence decline to 2001 (-35%) occurred after the introduction of the NSW Cervical Screening Program in 1992. This was followed 3 years later by a sustained mortality decline (-20%). During the 1990s survival across all degrees of spread remained unchanged and the mortality reduction was due entirely to reduction in incidence.

CONCLUSIONS

The substantial reduction of cervical cancer incidence and mortality in NSW over the last 3 decades is associated with important health service interventions that relate to control of cervical cancer, particularly the implementation of a population-based organised cervical screening program.

Follow-up of abnormal or inadequate cervical smears using two guidance systems: RCT on effectiveness

BACKGROUND

To improve follow-up compliance after an initial inadequate or abnormal cervical smear, two follow-up guidance systems were tested for effectiveness. A comprehensive system (cytopathology laboratory monitored the follow-up of all abnormal and inadequate smears) was compared to a selective system (monitoring was left to the smear taker; laboratory acted as a safety net).

METHODS

In an RCT on all family practices (N = 171) in the catchment areas of two cytopathology laboratories (Nijmegen region, The Netherlands, 1998-2000), practices were allocated at random to one of the follow-up guidance systems. All women included were registered at the practices, invited to the national screening program and had abnormal or inadequate smears. Measurements comprised of (1) follow-up compliance at baseline and 1 year after the initial smear and (2) diagnostic outcome of the follow-up smear.

RESULTS

During the study period, 132 practices sent their cervical smears to the laboratories. The comprehensive system covered 1226 women, the selective 1034. In the comprehensive system, the increase in follow-up compliance for initial inadequate and slightly abnormal smears was significantly higher (8.9%) than in the selective one, which implied an extra detection of eleven, more serious, abnormalities per 1000 women.

CONCLUSION

The comprehensive system was more effective than the selective and is suitable for use on a larger scale.

A Framework for the Development of MaternalQuality of Care Indicators

BACKGROUND

In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality.

OBJECTIVE

To develop potential indicators for the assessment of maternal health care quality.

MATERIALS AND METHODS

A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible.

RESULTS

Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits).

CONCLUSIONS

These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.

Interobserver agreement in the interpretation of anal intraepithelial neoplasia

BACKGROUND

Anal carcinoma incidence is increasing, and is highest among men with human immunodeficiency virus (HIV) infection who have sex with men. Anal carcinoma and anal intraepithelial neoplasia (AIN) are ascertained on tissue histology, but requires invasive procedures. Screening for AIN using anal cytology was suggested. The authors evaluated agreement on cytologic and biopsy specimens from HIV-positive men undergoing anal carcinoma screening.

METHODS

One hundred twenty-nine HIV-positive men with a history of anal-receptive intercourse underwent anal cytology, anoscopy, and biopsy. Four pathologists independently assessed cytology and biopsy specimens and reached consensus for discordant cases.

RESULTS

Each pathologist evaluated 120 cytology and 155 biopsy specimens. The weighted kappa value for overall agreement was 0.54 (95% confidence interval [CI], 0.49-0.59) for cytology specimens and 0.59 (95%CI, 0.55-0.63) for biopsy specimens. The median kappa values for pairwise agreement among pathologists and for agreement with consensus were, respectively, 0.69 and 0.77 for cytology and 0.66 and 0.75 for biopsy. At least 3 pathologists were in agreement for 92 (76.7%) cytology and 134 (86.5%) biopsy specimens. Reliability for the Bethesda classification system was at least moderate, except for the cytologic category of atypical squamous cells of undetermined significance (kappa = 0.12). Fourteen of 29 (48.3%) cytology specimens and 36 of 47 (76.6%) biopsy specimens with consensus interpretation of high-grade squamous intraepithelial lesions (HSIL) were interpreted originally as HSIL by > or = 3 pathologists. The kappa value for agreement with consensus distinguishing HSIL from non-HSIL ranged from 0.55 to 0.88 for cytology specimens and from 0.76 to 0.94 for biopsy specimens.

CONCLUSIONS

Agreement for cytologic and biopsy interpretations was generally at least moderate. Nevertheless, these results supported the need for disease indicators with greater reliability.

A phase I study to evaluate a human papillomavirus (HPV) type 18 L1 VLP vaccine

Human papillomavirus (HPV) infection can cause genital warts and cervical cancer. HPV types 6 and 11 cause >90% of genital wart cases; HPV16 and 18 cause 70% of cervical cancers. A prophylactic HPV (types 6, 11, 16, 18) L1 virus-like particle (VLP) vaccine may substantially reduce the incidence of these lesions. This report describes the results of a phase I study of the HPV18 component of such a vaccine. Forty women were randomized to receive either HPV18 L1 VLP vaccine or placebo. Anti-HPV18 responses were measured using a competitive radioimmunoassay (cRIA). Tolerability was evaluated using vaccination report cards (VRC). The study showed that the HPV18 L1 VLP vaccine was generally well-tolerated and highly immunogenic. Peak anti-HPV18 geometric mean titers (GMT) in vaccines were 60-fold greater than those observed in women following natural HPV18 infection. Further studies of a multivalent HPV L1 VLP vaccines are warranted.

Detection of cervical precancer and cancer in a hospital population; benefits of testing for human papillomavirus

The aim was to determine the relevance of human papillomavirus (HPV) testing in identifying high-grade cervical intraepithelial neoplasia or worse (CIN2/3+) in a hospital population (n=3574) characterised by a high rate of cytological abnormalities and high-risk HPV infections. According to the results of the initial Papanicolaou and HPV test, women were directly referred for colposcopy/biopsy or recalled for a control visit. Sensitivity and specificity were corrected for verification bias. HPV-testing sensitivity was 94.3%, higher than that of cytological testing at any cut-off point (65.1%-86.8%), while specificity was greater for cytology than for HPV testing (99.3% or 91.8% versus 83.4%). The combination of both tests allowed 100% sensitivity and negative predictive value. We conclude that HPV testing is a relevant tool for the detection of cervical disease. The best way of combining cytology and HPV detection in screening programmes should be evaluated in large-scale studies.

POBASCAM, a population-based randomized controlled trial for implementation of high-risk HPV testing in cervical screening: Design, methods and baseline data of 44,102 women

Cytological cervical screening is rather inefficient because of relatively high proportions of false negative and false positive smears. To evaluate the efficiency of high-risk human papillomavirus (hrHPV) testing, by GP5+/6+ PCR-enzyme immunoassay (EIA), in conjunction with cytology (Intervention Group) to that of the classical cytology (Control Group), we initiated the Population Based Screening Study Amsterdam (POBASCAM). POBASCAM is a population-based randomized controlled trial for implementation of hrHPV testing in cervical screening. The outcome measure is the proportion of histologically confirmed > or =CIN3 lesions in each study arm up to and including the next screening round after 5 years. We present the design, methods and baseline data of POBASCAM. When, in the next 5 years, the follow-up will be completed, the data obtained will be used in model studies, including a cost-effectiveness study, to advise the Dutch Ministry of Public Health in deciding whether cervical screening should be based on combined hrHPV and cytology testing instead of cytology alone. Between January 1999 and September 2002, 44,102 women (mean age = 42.8 years; range = 29-61) that participated in the regular Dutch screening program were included in our study. In the Intervention Group the distribution of cytology and hrHPV by cytology class was as follows: normal cytology 96.6% (3.6% hrHPV positive); borderline and mild dyskaryosis (BMD) 2.5% (34.6% hrHPV positive); and moderate dyskaryosis or worse (>BMD) 0.8% (88.3% hrHPV positive), i.e., 0.4% moderate dyskaryosis (82.9% hrHPV positive), 0.3% severe dyskaryosis (92.5% hrHPV positive), 0.1% carcinoma in situ (95.2% hrHPV positive), <0.1% suspected for invasive cancer (hrHPV positive 100.0%). In the Control Group 96.5% of the women had normal cytology, 2.4% BMD and 0.8% >BMD, i.e., 0.4% moderate dyskaryosis, 0.3% severe dyskaryosis, 0.1% carcinoma in situ, <0.1% suspected for invasive cancer. The presence of hrHPV was age-dependent, decreasing from 12.0% at 29-33 years to 2.4% at 59-61 years. Among women with a positive hrHPV test, the prevalence of BMD was age-dependent ranging from 20.2% at 29-33 years to 7.8% at 54-58 years. In contrast, the risk of >BMD of 13.7% among women with a positive hrHPV test was not age-dependent. Our study indicates that large-scale hrHPV testing by GP5+/6+ PCR-EIA in the setting of population-based cervical screening is practically feasible, is accepted by both participating women and general practitioners and yields highly reproducible results.

Primary care cancer control interventions including Latinos: a review

BACKGROUND

Even though 86% of adult Latinos have a usual source of care, there is a paucity of literature on primary care-based interventions to promote cancer prevention and control in this population. This systematic review examines published primary care-based cancer control interventions that included Latinos.

METHODS

MEDLINE, the Cochrane Registry, and EMBASE were searched from January 1985 to January 2003. Any primary care-based intervention using a controlled trial, quasi-experimental, or pre-post design that targeted breast, cervical, or colorectal cancer was included if at least 5% of the sample was Latino.

RESULTS

A total of 14 intervention studies met inclusion criteria. Seven of the 14 studies described patient or provider reminder interventions. Other interventions incorporated into the primary care setting one of the following: community health educators, culturally sensitive videos, audit with feedback, materials from the "Put Prevention Into Practice" campaign, and vouchers for free screenings. The heterogeneity of designs and outcome variables and the low number of Latinos presented obstacles to combining data to estimate the overall effectiveness of primary care interventions for this population. Qualitatively, patient and physician reminders and management systems strategies including audit with feedback for providers appear to result in improved screening utilization.

CONCLUSIONS

There is a paucity of data on the effectiveness of primary care cancer control interventions directed at Latinos. Primary care-based interventions that have been effective in non-Latinos could incorporate culturally appropriate elements and lessons from community-based research and could be applied to Latinos so that their effectiveness can be assessed in this group.

Incidence and survival rate of women with cervical cancer in the Greater Amsterdam area

To evaluate the effect of population-based cervical cancer screening on the occurrence of cervical cancer in The Netherlands, we investigated the incidence and survival of cervical cancer registered by a cancer registry in the Greater Amsterdam area. The incidence rate of squamous cell carcinoma decreased significantly from 9.2/100,000 women in 1988 to 5.9/100,000 in 2000 (P<0.001). The incidence rate of adenocarcinomas remained stable. After adjustment for age, stage and lymph node involvement, the relative risk of death was 1.6 times higher for patients with adenocarcinomas than for patients with squamous cell carcinoma (95% CI 1.2-2.1). The decreased survival was related to histological type, as the effect remained significant after correction for confounding factors. Over time, the prognosis of women with squamous cell carcinoma improved significantly. No significant change was observed for women diagnosed with adenocarcinoma. These results suggest that the screening programme in The Netherlands as executed in the Greater Amsterdam area is associated with a decreased incidence and increased survival of patients with squamous cell carcinoma, but fails to detect (pre)malignant lesions of adenocarcinoma. Since more than 92% of adenocarcinomas and its precursors contain high-risk HPV, adding HPV testing to cytologic screening might improve the present screening programme in detecting adenocarcinoma and its precursor lesions.