Detection rates for abnormal cervical smears: what are we screening for?

Surveillance, knowledge and risk: the embodied experience of cervical screening

Risk and surveillance have emerged as two prominent themes concerning the substantive topic of public health and prevention. While these themes have largely been addressed as discrete issues within the sociology of health and illness, of late there has been a concerted effort to address the relationship between the two. This paper examines an aspect of prevention which is often implicitly identified in terms of both risk and surveillance; that of cervical screening in Britain. First I discuss how risk and surveillance have been brought together in the sociology of health and illness and outline some limitations in their application to substantive topics such as prevention. Second, I introduce cervical screening and proceed with a discussion of textual and interview data which throws light on the status of risk in cervical screening as both an objective and subjective category.

Prevalence of human papillomavirus in university young women

Cervical cancer is the second most prevalent female cancer worldwide. The majority of cases appear between the age of 30 and 50. Human papillomavirus (HPV) plays a central role in cervical cancer with 99.7% of HPV DNA identified in invasive cervical carcinomas. The prevalence of the HPV infection varies substantially among countries and according to age and lifestyle. HPV is a common sexually transmitted infection among males and females with a 70% higher incidence in sexually active females. This study aimed to determine the prevalence of human papillomavirus in young university women by analyzing the correlation between Papanicolaou (PAP)-stained cervical tests and HPV detection by genotyping, as well as other risk factors. A total of 200 women aged between 18 and 25 years were enrolled in this study, which took place between September 2008 and May 2009 at the Universidad de Tarapacá, Arica, Chile. Results of the PAP smears showed that 97.5% of cells had normal characteristics, although an inflammatory pattern was noted. The prevalence of generic HPV infection was 3.5% when testing for HPV DNA using the polymerase chain reaction (PCR) method. An analysis of the genotype of infected female individuals indicated that high-risk HPV types, such as HPV 16 and 31 were present in 42.84 and 14.29% of females, respectively, and low-risk types such as HPV 6, in 14.29%. Only one sample with differentiated non-HPV (14.29%) was found. A 95% correlation between PAP-stained cervical tests and the method of testing for HPV was observed. Using the PCR method, it was found that of the 195 negative PAP smears, 5 were positive for HPV and two of the samples that were positive for ASC-US were also positive. A significantly increased (P<0.05) HPV infection risk was observed in the 18-21 age group with a higher prevalence (71.40%) when compared to the 22-25 age group (28.6%). A significant (P<0.042) difference was found between smoking and HPV infection. In conclusion, a significant (P<0.05) correlation was found between PAP and PCR methods for HPV testing in young university women. A significant correlation between smoking and HPV was detected, whereas no difference was noted with other parameters.

Cervical screening in England: the past, present, and future

Cervical screening in England commenced in a disorganized fashion in 1964. The flaws of this approach became apparent in the mid-1980s and led to the inception of the National Health Service Cervical Screening Programme (NHSCSP). The main features of this program are its population-based registry, accessibility to all women within the screening age range, its systematic process of call and recall, national coordination, and quality assurance. Its success is in part based on its ability to evolve as evidence necessitates, and throughout the period of 2000-2010, it embarked upon a series of developments involving liquid-based cytology, which also provided the means to conduct reflex high-risk human papillomavirus (HR-HPV) testing and the potential to automate the screening process. As a result of evidence acquired since 2000, the NHSCSP is currently based on a system of primary cytology with HPV triage for low-grade abnormalities combined with cytology plus a HR-HPV "test of cure" for women who have received treatment for cervical intraepithelial neoplasia. Future challenges for the program will involve finding solutions to increasing screening uptake among women <30 years of age-a problem that may be exacerbated when vaccinated women reach the screening age, while making plans to accommodate HPV primary screening.

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.

Human papillomavirus testing on self-sampled cervicovaginal brushes: An effective alternative to protect nonresponders in cervical screening programs

Women not attending cervical screening programs are at increased risk of cervical cancer. We investigated in these nonresponders to what extent offering self-sampling devices for cervicovaginal brushes for high-risk human papillomavirus (hrHPV) testing would induce participation and, if so, what the yield of precursor (i.e. CIN2 or worse) lesions following self-sampling would be. In addition, we assessed screening history of participants and costs per detected high-grade CIN2 or worse ("CIN2+") lesion in comparison to the regular program in the Netherlands. Nonresponders received a device for hrHPV testing (self-sampling group, n=2,546) or an extra recall for conventional cytology (control group, n=284). The percentage of self-sampling responders were compared with responders in the recall group. hrHPV positive self-sampling responders were invited for cytology and colposcopy. CIN2+ yield and costs per detected CIN2+ were evaluated. Active response was higher in the self-sampling than in the control group (34.2 vs. 17.6%; p<0.001). hrHPV positive self-sampling responders were less likely to have a prior screening history than screening participants (p<0.001), indicating that they are regular nonresponders. hrHPV prevalence was similar (8.0 vs. 6.8%; p=0.11), but CIN2+ yield was higher in self-sampling responders compared to screening participants (1.67 vs. 0.97%; OR=2.93, 95% CI 1.48-5.80; p=0.0013). Costs per CIN2+ lesion detected via self-sampling were in the same range as those calculated for conventional cytological screening (euro 8,836 vs. euro 7,599). Offering self-sampling for hrHPV testing in nonresponders is an attractive adjunct to effectively increase population coverage of screening without the adverse effect of markedly increased costs per detected CIN2+ lesion.

Telomerase activity as an adjunct to high-risk human papillomavirus types 16 and 18 and cytology screening in cervical cancer

Telomerase is a ribonucleoprotein comprising an RNA template, the telomerase-associated protein and its catalytic subunit, human telomerase reverse transcriptase (hTERT). Telomerase activation is a critical step in cellular immortalisation and development of cancer. Enhanced telomerase activity has been demonstrated in cervical cancer. In the present study telomerase activity and hTERT mRNA expression were evaluated and correlated with the presence of human papillomavirus (HPV) infection and cytological changes in the cervical lesions. Telomerase activity was assayed by telomeric repeat amplification protocol, hTERT mRNA expression by reverse transcriptase polymerase chain reaction and presence of high risk HPV (HR-HPV) infection by polymerase chain reaction. Out of 154 cervical samples of different cytology, 90 (58.44%) were positive for HR-HPV types 16/18, while among 55 normal cervical scrapes, 10 (18.18%) were HPV DNA positive. All 59 invasive cancer samples showed a very high telomerase activity. Among dysplasia, seven (63.6%) mild dysplasia, 18 (100%) of moderate, 20 (100%) of severe dysplasia and 6 (100%) carcinoma in situ (CIS) samples were positive with mild to moderate to high to very high telomerase activity respectively. Seven (12.7%) samples of apparently normal cervical scrapes were weakly positive for telomerase activity. We observed a good correlation (P<0.001) between telomerase activity and HR-HPV 16/18 positivity with a sensitivity of 88.1% for HPV and 100% for telomerase activity. It is suggested that telomerase activity may be used as an adjunct to cytology and HPV DNA testing in triaging women with cervical lesions.

Effective screening for bowel cancer: a United kingdom perspective

Bowel cancer is a major cause of morbidity and death and is a high cost to health care systems. Screening currently offers the best chance of improving outcomes from bowel cancer. When introducing screening, the problems encountered in other cancers need to be avoided to maximize benefits and minimize harms.

Inducción sanitaria de los cribados: impacto y consecuencias. Aspectos éticos

The main aim of screening is to identify people with an increased probability to benefit from preventive interventions, generally from secondary prevention but also from primary prevention activities. The goal is to facilitate early diagnosis and treatment in order to modify positively the prognosis (the former case), or to recognize people exposed to risk factors which increase the incidence rate of disease, and then to prevent the disease (the latter case). Good intentions are not enough to achieve good results in terms of effectiveness, safety, efficiency or equity. It is necessary to have a systematic assessment of the consequences of screening, particularly on the impact on peoples health and on the health services. Due to the diversity of types of screenings that are done, it is very difficult to estimate the net impact caused by their implementation. Moreover, the changes in the health of a population depend on many factors other than health service interventions. Thus, it is very important to determine the effectiveness and safety of the screening methods that are most frequently applied. Unfortunately, assessment of the benefits and the harm potentially caused by preventive interventions has not been done often. In Spain only a few partial assessments have been published, and they focus on the activities and the processes themselves rather than the final outcomes. Given that screening activities are carried out in health care services, and that the populations screened are mostly healthy people, the ethical issues have great importance when health policies are designed and implemented. Thus, it is recommended that screenings activities be analyzed applying the ethical principles of autonomy, benefit, safety and justice. If any screening program cannot reasonably satisfy these principles then they should be removed from the list of public health activities that are financed by public resources. In the same sense, all screening procedures offered to the population must be subjected to a systematic evaluation of their effectiveness, safety, efficiency and equity in terms of how the procedure would be applied. Lastly, to achieve an effective implementation of the principle of autonomy as well the desired goal of empowering the population to exercise some control over their determinants of health, it is recommended to explore new ways of achieving active citizen participation to establish preventive priorities and to assess the impact of screening interventions.

Season, Sun, Sex, and Cervical Cancer

INTRODUCTION

Sunlight's UV B component, a known cellular immunosupressant, carcinogen, and activator of viral infections, is generally seasonally available. Venereal human papillomavirus (HPV) transmission, at least in part, causes cervical cancer. We have previously inspected the monthly rates of venereal HPV infection and sunlight fluency in Southern Holland over 16 consecutive years. Both peak in August with at least 2-fold seasonality. The amount of available sunlight and the rate of Papanicolaou (Pap) smear screen-detected HPV are positively correlated. We now investigate whether premalignant and malignant cervical epithelial changes are also seasonal and related to seasonal sunlight fluency.

METHODS

We have studied >900,000 consecutive, serially independent, interpretable screening Pap smears obtained by a single cervical cancer screening laboratory in Leiden, Holland, during a continuous 16-year span from 1983 through 1998. The average monthly rates of premalignant and malignant epithelial change were inspected and the annual patterns contrasted to the annual pattern of sunlight fluency at this global location and to monthly average HPV infection rate. Because HPV is venereally transmitted, Dutch seasonal sexual behavior was evaluated by assessment of the annual pattern of Dutch conception frequency as a competing cause for cervical cancer seasonality.

RESULTS

(a) Twice as many premalignant and malignant epithelial changes were found among Pap smears obtained in the summer months, with an August peak concurrent with histopathologic evidence of HPV infection and sunlight fluency in Southern Holland. (b) Monthly sunlight fluency is correlated positively with both the monthly rates of Pap smear-detected cervical epithelial dysplasia and carcinomatous histopathology, as well as HPV. (c) Conception frequency, in this location, peaks in Spring not summer, and has a 4.8% annual amplitude.

CONCLUSIONS

(a) Cervical epithelial HPV infection and HPV-induced cervical epithelial dysplasia and carcinomatous change may each be novel sun exposure risks and thereby behaviorably avoidable. (b) Because screening Pap smears uncover many abnormalities that resolve spontaneously (false positives), these data may argue for screening and follow-up Pap smear examinations in seasons other than summer in the Northern Hemisphere, to diminish the false-positive smear rate. Global data are available to confirm and further test each of these conclusions.

Knowledge of cervical cancer and screening among women in east-central England

This study assesses the extent and accuracy of women's knowledge of cervical cancer, risk factors, and the efficacy of the national screening program. Data were obtained from a questionnaire survey of randomly selected women eligible for screening, drawn from a population in east-central England. The majority of women in the sample overestimated the current incidence of cervical cancer, both absolutely and relative to other cancers. Perceiving incidence to be high was associated with reporting worries about the disease. With respect to the screening process, 78.3% believe that the smear abnormality rate is higher than it actually is, and only 7.6% correctly appreciate that the abnormality rate is highest at younger ages. With respect to performance, 16.3% believed the smear test to be completely accurate, and more than half overestimated the likely number of cancer cases prevented by screening. While certain cervical cancer risk factors were correctly assigned by the majority of women, undue emphasis was placed on genetic influence, while the risks posed by human papillomavirus infection were unfamiliar to almost half of the sample. We conclude that women typically possess only a partial picture of risk factors and overestimate both the incidence of cervical cancer and the efficacy of screening.

Screening for cervical cancer: will women accept less?

BACKGROUND

U.S. professional organizations increasingly agree that most women require Papanicolaou smear screening every 2 to 3 years rather than annually and that most elderly women may stop screening. We sought to describe the attitudes of women in the United States toward less intense screening, specifically, less frequent screening and eventual cessation of screening.

METHODS

We conducted a random-digit-dialing telephone survey of women in 2002 (response rate of 75% among eligible women reached by telephone). A nationally representative sample of 360 women aged 40 years or older with no history of cancer was surveyed about their acceptance of less intense screening.

RESULTS

Almost all women aged 40 years or older (99%) had had at least one Pap smear; most (59%) were screened annually. When women were asked to choose their preferred frequency for screening, 75% preferred screening at least annually (12% chose screening every 6 months). Less than half (43%) had heard of recommendations advocating less frequent screening. When advised of such recommendations, half of all women believed that they were based on cost. Sixty-nine percent said that they would try to continue being screened annually even if their doctors recommended less frequent screening and advised them of comparable benefits. Only 35% of women thought that there might come a time when they would stop getting Pap smears; of these, almost half would not stop until after age 80 years. The strongest predictor of reluctance to reduce the frequency of screening was a belief that cost was the basis of current screening frequency recommendations.

CONCLUSION

Most women in the United States prefer annual Pap smears and are resistant to the idea of less intense screening. Concern that cost considerations rather than evidence form the basis of screening recommendations may partly explain women's reluctance to accept less intense screening.

Predictive significance of the alterations of p16INK4A, p14ARF, p53, and proliferating cell nuclear antigen expression in the progression of cervical cancer

PURPOSE

The purpose of this research was to evaluate the clinical significance of p16INK4A, p14ARF, p53, and proliferating cell nuclear antigen (PCNA) expression in tumor progression of cervical cancer.

DESIGN

Seventeen patients (40 samples) with consecutive cervical lesions from normal squamous epithelium, inflammation of the cervix to cervical intraepithelial neoplasm (CIN) and invasive cervical squamous cell cancer (SCC), or from CIN to SCC were collected for this study. Expression of p16INK4A, p14ARF, p53, and PCNA were detected by immunohistochemistry on paraffin-embedded sections. Human papillomavirus DNA was detected simultaneously with PCR and typed according to its DNA sequence.

RESULTS

p16INK4A overexpression was significantly higher in CIN (75%) and in SCC (75%) than in normal or inflammation of the cervix (12.5%; P < 0.01, P < 0.05, respectively). The positive rate of p14ARF expression was higher in SCC (83%) than in normal/inflammation of the cervix (25%; P < 0.05). PCNA expression was negative in normal or inflammation of the cervix, but an increased in expression was seen in 63.2% in CIN and 100% in SCC (P < 0.01, P < 0.05). When the time interval for disease progression from initial biopsy to CIN 3 or invasive cancer was compared with states of p16INK4A expression, cases stained positive for p16INK4A progressed within 64.2 months as compared with 122.3 months among those stained negatively (P < 0.01). Cases with increased p14ARF expression also had a short time interval for disease progression of 78.8 months as compared with 108.3 months in cases that were p14ARF negative. Cases with stable or decreased p53 expression had the shortest time interval for progression of 32.3 months in contrast to cases with no p53 expression (113.9 months). However, cases with increasing p53 expression progressed within 60.8 months.

CONCLUSIONS

Our results suggested that altered states of p16INK4A, p14ARF, p53, and PCNA may be valuable markers to predict the progression of cervical neoplasia.

Systematic review of the literature on postpartum care: selected contraception methods, postpartum Papanicolaou test, and rubella immunization

BACKGROUND

The postpartum period is a time when many routine interventions are provided to mothers. This review examined the published evidence for the effectiveness of selected contraceptive methods, Papanicolaou (Pap) tests, and rubella immunization.

METHODS

MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women. The initial literature search was done in 1999, and was enhanced in 2003. Studies were categorized and reviewed by topic areas. Data were extracted in a systematic method, and the quality of each study was reviewed.

RESULTS

In the 1999 search, 140 studies were randomized controlled trials that met the selection criteria: 5 related to postpartum contraception, 1 to timing of the postpartum Pap test, and 2 to postpartum rubella immunization. In the 2003 searches, 1 additional study related to postpartum contraception was identified. From the published literature on selected contraceptive methods, the intrauterine devices examined were effective in preventing pregnancy and had comparable side effect profiles. No clear recommendation can be made because insertion timing was not randomized in the included trials. Although delaying the postpartum Pap smear until 8 weeks reduces the proportion of inflammatory smears, it is uncertain whether a Pap smear is of benefit to postpartum women. The RA 27/3 postpartum rubella vaccine appears to be more effective than the Cendehill vaccine, but a small proportion of women may develop acute and chronic joint manifestations.

CONCLUSIONS

Some evidence is available to support selected postpartum contraceptive methods and the postpartum rubella vaccine, but data are lacking on the effectiveness and optimal timing of the postpartum Pap smear.

The cervical cancer epidemic that screening has prevented in the UK

BACKGROUND

Recent reports suggest that the reduction in mortality achieved by the UK national cervical screening programme is too small to justify its financial and psychosocial costs, except perhaps in a few high-risk women.

METHODS

We analysed trends in mortality before 1988, when the British national screening programme was launched, to estimate what future trends in cervical cancer mortality would have been without any screening.

FINDINGS

Cervical cancer mortality in England and Wales in women younger than 35 years rose three-fold from 1967 to 1987. By 1988, incidence in this age-range was among the highest in the world despite substantial opportunistic screening. Since national screening was started in 1988, this rising trend has been reversed.

INTERPRETATION

Cervical screening has prevented an epidemic that would have killed about one in 65 of all British women born since 1950 and culminated in about 6000 deaths per year in this country. However, these estimates are subject to substantial uncertainty, particularly in relation to the effects of oral contraceptives and changes in sexual behaviour. 80% or more of these deaths (up to 5000 deaths per year) are likely to be prevented by screening, which means that about 100000 (one in 80) of the 8 million British women born between 1951 and 1970 will be saved from premature death by the cervical screening programme at a cost per life saved of about pound 36000. The birth cohort trends also provide strong evidence that the death rate throughout life is substantially lower in women who were first screened when they were younger.

Atypical squamous cells of undetermined significance: audit and the impact of potential litigation. Retrospective review of 682 cases

For quality assurance purposes, the frequency of 'abnormal' cytological diagnoses of the non-systematic National Cervical Cancer Screening Programme (NCCSP) was evaluated. In 1999, an unexpected high number of Class (Cl) III cases (i.e. atypical squamous cells of undetermined significance) was reported. The cytological and histological results were reviewed in order to detect a possible cause for this threefold increase. The abnormal Papanicolaou (PAP) smears examined by conventional methods from 1 January 1990 to 31 December 2002 were analysed. The smears of 682 cases diagnosed in 1999 with a Cl III category were reviewed in 2000 and correlated with the available histological diagnoses provided by the Central Department of Pathology. Of the 682 Cl III cases, 176 cases (26.1%) had no follow-up, 314 cases (46.0%) had repeat cytology and 192 cases (28.2%) an histological correlate corresponding to 90 (46.9%) benign lesions, 78 (40.6%) squamous intraepithelial lesions, two (1%) invasive cervical cancers (one squamous and one glandular). Twenty-two Cl III cases (11.5%) were histologically within normal limits. Retrospective smear review confirmed 330 Cl III diagnoses (48.3%), 127 cases (18.6%) were recategorized as Cl IIIG (i.e. atypical glandular cells of undetermined significance), 22 cases (3.2%) as Cl IIID (i.e. mild to moderate dysplasia) and six cases (0.9%) as Cl IVa (i.e. severe dysplasia and/or carcinoma in situ). A total of 197 original Cl III cases had to be reclassified in the Cl II category (28.9%), only two cases showing mild and moderate dysplasia on histology. Thus, 195 cases (28.6%) comprised cytological overdiagnoses. The Cl III category being, by definition, a delicate and often subjective diagnosis, all external influences such as pressure of litigation should be avoided to reduce cytological overdiagnoses as a result of an unnecessary 'fear-factor'.

Randomised controlled trial of the effect of evidence based information on women's willingness to participate in cervical cancer screening

STUDY OBJECTIVE

To assess whether providing women with additional information on the pros and cons of screening, compared with information currently offered by the NHS, affects their intention to attend for screening.

DESIGN

Randomised controlled trial. Participants were randomly assigned to receive either the control, (based on an NHS Cervical Screening Programme leaflet currently used), or the intervention leaflet (containing additional information on risks and uncertainties).

SETTING

Three general practices in Birmingham.

PARTICIPANTS

300 women aged 20 to 64 attending the practices during a one month period.

MAIN OUTCOME MEASURES

Intention to attend for screening.

MAIN RESULTS

283 women (94.3%) completed the study. Fewer women in the intervention (79%) than the control group (88%) expressed intention to have screening after reading the information leaflet (difference between groups 9.2%, 95% confidence intervals (CI) 3.2% to 21.7%). The crude odds ratio (OR) and 95% CI was 0.50 (0.26 to 0.97). After adjusting for other factors, the trend persisted (OR 0.60, 95% CI 0.28 to 1.29). Having a previous Pap smear was the only significant predictor of intention to have screening (adjusted OR 2.54, 95% CI 1.03 to 6.21). Subgroup analysis showed no intervention effect in intended uptake between women at higher and lower risk of cervical cancer (p=0.59).

CONCLUSIONS

Providing women with evidence based information on the risks, uncertainties, and the benefits of screening, is likely to deter some, but not differentially those at higher risk.

The clinician's view: role of human papillomavirus testing in the American Society for Colposcopy and Cervical Pathology Guidelines for the management of abnormal cervical cytology and cervical cancer precursors

The American Society for Colposcopy and Cervical Pathology (ASCCP) National Consensus Conference for the Management of Women With Cervical Cytological Abnormalities and Cervical Cancer Precursors was held on the National Institutes of Health campus in Bethesda, Md, September 6-8, 2001. The conference was attended by 121 representatives from 29 national organizations interested in cervical cancer screening issues. For the first time, guidelines for the management of women with abnormal cervical cytology, developed from evidence-based literature, were presented to delegates from the majority of organizations with interest in cervical cancer screening, voted on, and revised when necessary to achieve a majority two-thirds approval. This development of consensus-approved guidelines is likely to be considered one of the most important milestones to date in the management of women with abnormal cervical cytology. The timing of this Consensus Conference resulted from the convergence of many different factors, including new cytologic terminology developed at the Bethesda 2001 workshop and publication of the enrollment data from the National Cancer Institute's Atypical Squamous Cells of Undetermined Significance (ASC-US)/Low-Grade Squamous Intraepithelial Lesions (LSIL) Triage Study, otherwise known as ALTS. Additionally, new preliminary longitudinal ALTS data provided much of the information on the natural history of abnormal Papanicolaou tests and cervical intraepithelial neoplasia (CIN), as well as data on the performance of both new liquid-based cytology and human papillomavirus (HPV) DNA testing in the management of women following colposcopy. The result was a large database of new information that provided the foundation for the ASCCP Consensus Conference. This article covers only the recommendations of the ASCCP Guidelines that were based in large part on the results of the ALTS trial. Therefore, the focus is on the management of women with equivocal (ASC-US) and low-grade (LSIL) cytologic abnormalities. Management of women with these cytologic abnormalities has been particularly problematic, because individually these women are at least risk for CIN 3 and cancer, yet their sheer numerical dominance ensures that they account for the majority of high-grade CIN detected in the United States in the follow-up of abnormal cervical cytology. Data from ALTS confirmed that women with ASC-US could be safely managed by any of the conventional approaches (repeat Papanicolaou test, immediate colposcopy, or HPV testing), but that the preferred management approach for women having an ASC-US report from liquid-based cytology was to assess the patient's risk by testing for HPV. Additionally, longitudinal ALTS data determined that repeat liquid-based cytology at 6 and 12 months and an HPV test at 12 months were nearly equivalent options in the follow-up of women referred for HPV-positive ASC or LSIL, yet not found to have CIN 2+ at initial colposcopy. Therefore, all follow-up recommendations for women with CIN 1 or lower postcolposcopy findings include these 2 options. The data and the recommendations for the management of ASC-US, ASC cannot exclude high-grade squamous intraepithelial lesion, and LSIL are discussed.

Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented

OBJECTIVE

To determine the frequency of different outcomes in women participating in cervical screening.

DESIGN

Analysis of screening records from 348 419 women, and modelling of cases of cervical cancer and deaths with and without screening.

SETTING

Cervical screening programme in Bristol.

RESULTS

For every 10 000 women screened from 1976 to 1996, 1564 had abnormal cytology, 818 were investigated, and 543 had abnormal histology. One hundred and seventy six had persistent abnormality for two years or more. In the absence of screening 80 women would be expected to develop cancer of the cervix by 2011, of whom 25 would die. With screening 10 of these deaths would be avoided. Comparison of cumulative abnormality rates with numbers expected to develop cancer in the absence of screening suggests that at least 80% of high grade dyskaryosis and of high grade dysplasia would not progress to cancer. The lifetime risk of having abnormal cytology detected could be as high as 40% for women born since 1960.

CONCLUSIONS

Screening is labour and resource intensive. It involves treatment for many women not destined to develop invasive cancer. The increased intervention rate for cervical abnormality in England is due to change in practice, not a cohort effect, and is probably the reason for the marked fall in incidence and mortality during the 1990s. For other cancers there is scope for major iatrogenic harm from screening because of invasive tests and treatments.

Low risk of cervical cancer during a long period after negative screening in the Netherlands

A condition for effective cervical cancer screening is a low incidence of cervical cancer after negative screening compared to that in the absence of screening. This relative risk was studied for the period 1994-1997 in the Netherlands and compared with previous studies. All cases of invasive cervical cancer diagnosed from 1994 to 1997 in the Netherlands were related to woman-years at risk, stratified by age, number of preceding negative screenings and time since the preceding negative screening. These incidence rates were compared with that before screening started in the Netherlands. The relative risk increases from 0.13 in the first year after screening to 0.24 after more than 6 years after screening for women with one previous negative screening. These figures reduce to 0.06 and 0.18, respectively, for women with two or more previous screenings. However, these estimates are less favourable when account is taken of the likely decrease in risk for cervical cancer in the period studied. Our data show a low relative risk of cervical cancer for several years following the last negative Pap smear. However, the denominator of the relative risk, that is, the incidence without screening, may have been overestimated. This applies also to the IARC multicountry study, and may have caused too optimistic expectations about the effectiveness of cervical cancer screening.

Detection of telomerase, its components, and human papillomavirus in cervical scrapings as a tool for triage in women with cervical dysplasia

AIM

To examine whether the detection of either telomerase and its components or high risk human papillomavirus (HPV) are of value in predicting the presence of cervical intraepithelial neoplasia (CIN) grade II/III in women referred because of cervical cytology reports showing at most moderate dyskaryosis.

METHODS

Cervical scrapings of 50 women referred with cytological borderline, mild, or moderate dyskaryosis were analysed. Telomerase activity was assessed by a commercially available telomere repeat amplification protocol assay and its components human telomerase RNA (hTR) and human telomerase reverse transcriptase (hTERT) were assessed by reverse transcriptase polymerase chain reaction (PCR). HPV was detected by GP5+/6+ PCR enzyme immunosassay. Histological findings on colposcopy guided biopsies or excised cervical tissue were regarded as the final pathological diagnosis. The sensitivity and specificity for detecting CIN II/III were calculated.

RESULTS

Twenty eight women were diagnosed with CIN II/III. Telomerase activity was detected in none, hTR in 88%, hTERT in 23%, and high risk HPV was detected in 79% of these women. As a diagnostic test none of the described analyses combined a sensitivity of at least 90% with a specificity >or= 90%. Despite the small numbers, calculation of the 95% confidence intervals excluded a combined sensitivity and specificity of at least 90% for all of the evaluated parameters.

CONCLUSIONS

Neither detection of telomerase or its components, nor detection of high risk HPV seem suitable for the triage of women with borderline, mild, and moderate cytological dyskaryosis.

Trend of cervical cancer mortality in Belgium (1954-1994): tentative solution for the certification problem of unspecified uterine cancer

We investigated the evolution of mortality from cervical cancer in Belgium between 1954 and 1994 in terms of absolute number of deaths, and standardised and age-specific mortality rates. Changes over generations were summarised using the standardised cohort mortality ratio. Trend studies of cervical cancer mortality were hampered by certification problems. The number of deaths due to cancer of the uterine cervix is not known exactly since a substantial proportion of death causes are coded as cancer of the uterus without specifying the anatomic site: cervix or corpus uteri. This inaccuracy in codification has been corrected using distribution tables derived from countries where this certification problem is minimal. Trends in mortality from certified and corrected cervical cancers were compared. The corrected age-standardised mortality rate decreased continuously over the last 4 decades, from over 14 to 5 per 100,000 woman-years (slope -0.26/100,000 woman-years, 95% CI -0.28 to -0.24). Its slope is 3.1 times (95% CI 2.9-3.5) more important than for the rate of mortality from certified cervical cancer. In addition to the almost linear decrease, substantial nonlinear cohort influences were observed in certified and corrected mortality rates. The tendency of increasing mortality in women born after 1935 required particular attention. Nevertheless, the slope of the corrected recent cohort effect remained limited in Belgium, probably as a consequence of screening.

Paying for prevention standardizing the measurement of the value of health care interventions

It is not clear if spending more on tests that enhance the accuracy of Pap smears would lead to a greater reduction in cancer incidence than if the money were spent to include a greater proportion of women in primary screening. The cost effectiveness of tests beyond the Pap smear has not been clearly demonstrated. There is the question of whether cervical cancer incidence can be decreased more by improving the tests for patients who are already screened or by improving access to the unscreened population. Cervical cancer screening represents only one of many public health issues competing for resources. Given that there are choices to be made, the optimal yardstick against which all resource-competing programs are measured should be marginal benefit versus marginal cost.

Communicating mild and borderline abnormal cervical smear results: how and what are women told?

The way in which women are informed about borderline or mild smear results can have a significant psychological impact. By means of a questionnaire survey of general practices in Nottingham, England, this study audited the means by which abnormal smear results were normally communicated to subjects and analysed the content of these communications. Transmitting abnormal smear results, either by letter or by telephone call, was typically the responsibility of the practice nurse, and communications varied widely in informational content. We conclude that the method and content of communications imparting mild or borderline smear results differs between general practices, even within a small geographical area.

p16INK4a immunohistochemistry improves interobserver agreement in the diagnosis of cervical intraepithelial neoplasia

It has been repeatedly shown that there is a substantial lack of interobserver reproducibility in the histologic diagnosis of cervical intraepithelial neoplasia (CIN), which might be improved by a more specific diagnostic biomarker. Cervical cancer and CIN, but not other cervical epithelia, express high levels of the cyclin-dependent kinase inhibitor p16, suggesting that staining for this marker could help to more precisely identify CIN in tissue sections and therefore reduce variation in interpretation of cervical lesions. To test this hypothesis, 194 cervical cone biopsy samples were selected from a routine histopathology laboratory. Two consecutive sections from each biopsy were stained with hematoxylin and eosin and with a p16 -specific monoclonal antibody, respectively. Five experienced cervical pathologists examined the slides. The agreement in the diagnosis between pairs or groups of observers was calculated by kappa statistics. Significant discrepancies were observed in the diagnostic interpretation of hematoxylin and eosin-stained slides, particularly for low-grade lesions (kappa value 0.60 [95% confidence interval 0.58-0.63]). There was significantly better agreement in the interpretation of p16 expression (kappa value 0.91 [95% confidence interval 0.84-0.99]). Expression of p16 was restricted to CIN 2/CIN 3, CIN 1 associated with high-risk human papillomavirus, or cervical cancer. p16 immunostaining allowed precise identification of even small CIN or cervical cancer lesions in biopsy sections and helped to reduce interobserver variation in the histopathologic interpretation of cervical biopsy specimens. Thus, p16 immunohistochemistry can reduce false-negative and false-positive biopsy interpretation and thereby significantly improve cervical (pre)-cancer diagnosis.

Screening for cervical disease in mature women: strategies for improvement

BACKGROUND

Cervical carcinoma remains a significant health risk for the older woman. In the current study the yield of screening of mature women in an established, opportunistic screening program was examined. Strategies for improving screening in this age group were identified through examination of recent Pap test history of women with high grade squamous intra-epithelial lesions (HSIL).

METHODS

From the population based registry of the Ontario Cervical Screening Program, the Pap test cytodiagnoses for almost 700,000 women screened during the first six months of 2000 were classified by age quintile. Screening yields for younger women (< 50 years of age) and mature women (>/= 50 years of age) were compared using the detection ratio (abnormalities per 1000 women tested). Any pap test results during the three years preceding a diagnosis of HSIL in mature women were identified (excluding any Pap test in the six months immediately prior to the HSIL cytodiagnosis) and classified into one of three categories: no prior test known, prior negative Pap test known, and prior abnormal Pap test known.

RESULTS

Twenty four percent of all Pap tests in the six month period were from mature women. Approximately 11% of all cytodiagnoses of HSIL and carcinoma (HSIL+), and 13% of all low grade squamous intra-epithelial lesions (LSIL), HSIL, carcinoma, and atypical glandular cells of uncertain significance (AGUS); [LSIL+ and AGUS] cytodiagnoses, were from mature women. The yield of Pap testing in mature women (1.7 HSIL+ per 1000 women tested) was slightly more than 40% of that for younger women (4.2 HSIL+ per 1000 women tested). Mature women with HSIL were more likely to have had a history of no prior screening (61.1%) than younger women (49.5%). The majority (62.9%) of mature women with HSIL and a prior known Pap test had a prior registered abnormal Pap test.

CONCLUSIONS

Pap testing of mature women yields a significant number of abnormalities, but is less efficient than Pap testing of younger women. Screening yield could be increased by recruiting mature women who are currently inadequately screened and by revising guidelines for cessation of screening. Proper followup of mature women with Pap test abnormalities would improve clinical outcome but could adversely affect the yield of Pap testing, since current inappropriate repeat testing of women would decrease.

Primary screening for high risk HPV by home obtained cervicovaginal lavage is an alternative screening tool for unscreened women

BACKGROUND/AIMS

Self sampling is considered an adjuvant tool to facilitate the participation of women in cervical cancer screening programmes. This study aimed to evaluate whether cervicovaginal lavage could be an alternative for the cervical smear in cytology and human papillomavirus (HPV) testing and to assess the acceptance of the self sampling device by women.

METHODS

Fifty six women with abnormal cervical cytology (very mild dyskaryosis or worse) and 15 women with normal cervical cytology obtained a self collected cervicovaginal lavage at home and filled in a questionnaire on the use of the device. At the colposcopy clinic the gynaecologist performed the same procedure followed by a cervical smear for cytology and HPV DNA testing.

RESULTS

The self sampling device was acceptable to 88% of the women. The concordance between the cytology results in the smear and the lavage by the doctor and the patient was 54% and 41%, respectively (kappa = 0.28 and 0.14). The concordance between high risk HPV detection in the smear and the lavage by the doctor and the patient was 93% and 78%, respectively (kappa = 0.82 and 0.53). Ninety one per cent of the women with high grade cervical intraepithelial neoplasia (CIN) had a high risk HPV positive test in the smear, compared with 91% and 81% in the lavages taken by the doctor and the patient, respectively.

CONCLUSIONS

HPV DNA testing by home obtained samples is useful as a screening tool for cervical cancer, whereas cervical cytology by self sampling is not. Although the sensitivity for high grade CIN by high risk HPV testing in the lavage by the patient is not significantly lower than that in the cervical smear, self sampling for HPV DNA is a feasible alternative method in women who decline to participate in population based cervical cancer screening programmes. However, participation in the screening programme remains the best option.

Pap test results among low-income youth: prevalence of dysplasia and practice implications

OBJECTIVES

To describe Papanicolaou (Pap) test findings and identify prevalence and correlates of dysplastic cervical abnormalities in low-income adolescent females.

DESIGN AND SETTING

This cross-sectional study included a modified random sample of female students ages 16 to 25 years at 54 U.S. Job Corps centers.

PARTICIPANTS

5,734 female students enrolled in a federal job training program. Admission health records were reviewed and abstracted.

MAIN OUTCOME MEASURE

Pap test findings using the Bethesda classifications. Pap smear results indicating dysplasia (atypical squamous cells of undetermined significance [ASCUS] with dysplasia) or squamous intraepithelial lesions (low-grade squamous interepithelial lesions [LGSIL] or high-grade squamous intraepithelial lesions [HGSIL]). Participants with less severe findings were compared with those who needed follow-up.

RESULTS

For 71.4% of participants, no abnormalities were found. 15.6% had benign cellular changes, 9.2% had reactive changes, and 9.9% had epithelial cell abnormalities. Of those tested, 5.6% (+/- 0.8%) had dysplastic Pap smear findings, with 0.3% (n = 12) HGSIL. All groups were equally affected, with abnormalities not associated with race/ethnicity, age, geographic region, education level, size of city of residence, or receiving public assistance.

CONCLUSIONS

In this population, dysplastic Pap smear results were not uncommon. Findings indicate that Pap screening, alone or in combination with more sensitive tests, can identify cervical abnormalities, including HGSIL, that suggest a need for further evaluation or follow-up.

Women who participate in spontaneous screening are not at higher risk for cervical cancer than women who attend programme screening

Up to 1995, programme screening for cervical cancer in The Netherlands was targeted at women between 35 and 54 years of age at 3-yearly intervals. Spontaneous screening in addition to programme screening was common practice. Our aim was to compare the underlying risk for cervical neoplasia for women involved in both types of screening. From the national pathological database, we retrieved all primary smears (n=693318) taken in 1994 in The Netherlands. Among the smears registered for screening purposes (39%), 79% was taken within the mass screening programme and 21% was taken for spontaneous screening. The underlying risk was studied from the detection rates of histologically confirmed severe dysplasia or worse, using a multivariate loglinear model, including age and screening history. The detection rate of at least severe dysplasia, adjusted for age and screening history, was equal for women who had a spontaneous smear and for those who had a programme smear (odds ratio (OR): 0.97; 95% Confidence Interval (CI): 0.84-1.14). In our data, women participating in spontaneous screening were not at a higher risk for cervical cancer than women who used programme screening. Therefore, all asymptomatic women in the Netherlands should follow the general guidelines for age-range and screening-interval.

Psychosocial and economic aspects of a trial of management of mild and borderline cervical abnormalities (TOMBOLA)

TOMBOLA is a randomized controlled trial to determine (a) the most effective and efficient management strategy for women with borderline or mildly dyskaryotic cervical smear results, and (b) the most appropriate treatment for women with abnormalities detected following colposcopy. This paper outlines the trial's psychosocial and economic protocol, and explains how TOMBOLA can provide detailed evidence on the psychosocial and economic impact of alternative management options and follow-up. This protocol has been developed in parallel with the clinical protocol, thereby offering the opportunity for the development of a type-specific outcome measure and detailed piloting of all instruments. The multi-disciplinary approach to TOMBOLA allows the combination of clinical outcomes with both generic and specific psychosocial and health-related quality of life measures. The convergent validity between these measures will be assessed, with a view to developing a specific utility index for the future assessment of cervical screening modalities.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

Cervical cancer is the third most common cancer world-wide. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing uptake, and informed uptake of cervical cancer screening.

SEARCH STRATEGY

Twenty-three electronic databases (to March 2000) were searched with no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs), or quasi-RCTs of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Data on study characteristics and quality were extracted independently by two reviewers. Where data were available, relative risks and 95% CI were calculated and a chi-squared test for heterogeneity was performed.

MAIN RESULTS

Thirty-five studies were included (27 RCTs and eight quasi-RCTs). Heterogeneity between studies limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. The number and quality of included studies limited evidence regarding effectiveness of other interventions. Informed uptake of cervical screening was not considered by any studies.

REVIEWER'S CONCLUSIONS

There was some evidence to support the use of invitation letters to increase the uptake of cervical screening. There was limited evidence to support educational interventions but it was unclear what format was most effective. The majority of the studies were from developed countries and so the relevance to developing countries is unclear.

[Descriptive study of cervical intraepithelial neoplasia grade III (CIN III) cases in the area of the hospital of Barbastro]

OBJECTIVE

A description of early diagnosis of cervical cancer in the Barbastro Hospital area.

DESIGN

Descriptive and retrospective study on all the CIN III cases collected in the Tumor Hospital Registry from 1989 to 1998. To correlate the data to the population covered by the hospital.

PARTICIPANTS AND METHODS

59 CIN III cases were detected and 16 invasive cancers. The total smears studied were 31409. The population covered was 50220 women, 15% of whom are between the age of 35 and 64.

RESULTS

The frequency of CIN III was 12 cases per 100000 women and year and of invasive cancers 3.2. From 59 CIN III 20 belong to the first five-year period and 39 to the second. The mean age was 37 12 (20-82). No significant statistical differences were found between five-year periods. The most frequent decade was 30-39 years (50% of cases). 10489 smears were studied from the first five-year period and 20911 from the second. 75% of invasive cases did not come from screening.

CONCLUSIONS

The tendency is that when the number of screened smears increases so does the number of CIN III. The frequency of the preneoplastic disease and invasive cancer is low. Therefore, close coordination between hospital departments of gynaecology and pathology together with primary health care is vital in order to extend the coverage, to reach risk groups and rationalise the screening of cervical cancer.

Primary screening for human papillomavirus infection

As human papillomavirus infection is now known to be a necessary risk factor for at least 95% of cervical cancers, the medical community has a responsibility to assess and evaluate how this knowledge should best be used for the prevention of cervical cancer. Organized screening strategies combining cytological screening with human papillomavirus testing in older age groups could theoretically be more sensitive than current screening programmes in reducing the incidence of cervical cancer. If it is possible safely to extend the screening interval in human papillomavirus-negative women, such programmes could also both be more effective and more cost-efficient. Although some modelling studies have indicated that this could indeed be the case, evidence from clinical trials evaluating the long-term protective effect of primary human papillomavirus screening is still lacking. The key issues on the research agenda for primary human papillomavirus screening are reviewed.

Information about screening - is it to achieve high uptake or to ensure informed choice?

For many years, public information about screening has been aimed at achieving high uptake but concerns are now being raised about this approach. There are several problems that have prompted these concerns. By giving information that emphasizes only the positive aspects of screening the autonomy of individuals is ignored, individuals feel angry when they perceive that they are let down by screening, symptoms may be disregarded because of the belief that screening gives full protection, health service staff carry the blame for problems that are in fact inherent in screening, and sound debate about policy and investment in screening is hampered by misunderstanding about the benefits and costs of screening. If we adopt instead an approach that makes explicit the limitations and adverse effects then a different set of problems will be encountered. We risk a reduction in uptake of screening and thus population benefits may reduce, those most likely to be deterred from accepting screening may be the most socially disadvantaged, there will be a cost in terms of staff time to explain screening more fully to participants, and cost-effectiveness could be reduced if uptake falls so low as to make services barely viable. In the UK current General Medical Council (GMC) advice to doctors about informed consent for screening makes it clear that full information should be given. The UK National Screening Committee has also signalled the need for a changed approach to information giving so that individuals are offered a choice based on appreciation of risks and benefits. It will take time for this approach to be fully reflected across the full range of UK screening programmes. New national information will be needed to assist staff in giving full information, and some aspects of policy, such as screening coverage targets for Health Authorities and General Practitioners, will need to be altered. There are many questions still to be answered about the kind of information needed to achieve informed participation, and about how it should be framed and communicated. These questions can begin to be addressed when there is clarity at national level about the purpose of information about screening.

Natural history of cervical human papillomavirus infection in young women: a longitudinal cohort study

BACKGROUND

Laboratory and epidemiological research suggests an association between human papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN). We studied the natural history of incident cervical HPV infection and its relation to the development of CIN.

METHODS

We recruited 2011 women aged 15-19 years who had recently become sexually active. We took a cervical smear every 6 months and stored samples for virological analysis. We immediately referred all women with any cytological abnormality for colposcopic assessment, but postponed treatment until there was histological evidence of progression to high-grade CIN.

FINDINGS

In 1075 women who were cytologically normal and HPV negative at recruitment, the cumulative risk at 3 years of any HPV infection was 44% (95% CI 40-48): HPV 16 was the most common type. The cumulative risk at 3 years of detecting an HPV type not present in the first positive sample was 26% (20-32). 246 women had an abnormal smear during follow-up, of whom 28 progressed to high-grade CIN. The risk of high-grade CIN was greatest in women who tested positive for HPV 16 (risk ratio 8.5 [3.7-19.2]); this risk was maximum 6-12 months after first detection of HPV 16. All HPV types under consideration were associated with cytologically abnormal smears. Although abnormality was significantly less likely to be associated with low-viral-load samples, the cumulative risk at 3 years of a high-viral-load sample after a low-viral-load sample was 45% (95% CI 35-56). Five women who progressed to high-grade CIN consistently tested negative for HPV.

INTERPRETATION

Our findings suggest that attempts to exploit the association between cervical neoplasia and HPV infection to improve effectiveness of cervical screening programmes might be undermined by the limited inferences that can be drawn from the characterisation of a woman's HPV status at a single point in time, and the short lead time gained by its detection.

The screening history of women with cervical cancer in the Rotterdam area

OBJECTIVE

In order to gain insight into the diagnostic effectiveness of the screening program on cervical cancer in the Rotterdam area, the history of women with cervical cancer was studied. Three questions were asked: (1) What percentage of women were invited to the screening program, and what percentage participated. (2) What percentage of women had had a negative smear within 3 years before cancer was diagnosed, and (3) What percentage of women encountered inadequate follow-up.

METHODS

All the cytological and histological results of women who were diagnosed with cervical carcinoma between 1992-1994 were studied.

RESULTS

Within 3 years of the diagnosis, 42% of the 165 women with cervical cancer were invited for the cervical screening program. A total of 47% were too old to be invited and 10% were too young. A total of 37% of the women who were invited participated in the screening program. A total of 33 (20%) of 165 women with cervical carcinoma had had a negative smear within three years preceding the diagnosis. For women under 34 years of age this was 41% (n = 7), and for women over 56 years 8% (n = 6). A total of 7% of all women with cervical cancer encountered inadequate follow-up.

CONCLUSION

Many women with a diagnosis of cervical cancer are too old to be invited for the cervical screening program. Relatively few of the women with cervical cancer who were invited for the screening program actually participated in this program.

[Precancerous lesions of the uterine cervix in cameroonian women. Cytological and epidemiological aspects of 946 cases]

OBJECTIVE

The aim of this study was to present the cytological and epidemiological aspects of precancerous lesions of the uterine cervix of women living in the two first cameroonian cities (Yaounde and Doubla).

MATERIAL AND METHODS

The material was made of pap smears registrar of the Yaounde Central Hospital pathological laboratory and the reports of cervical cancer screening from Douala and Yaounde within a period of five years (1st January 1994 to 31st December 1998). We recruited all cases showing a precancerous lesion of the uterine cervix. For each case, we noted: the type of lesion, the age of the patient, the age at the first sexual intercourse, the age at the first delivery, the number of pregnancies, the parity, the marital status, the socioeconomical class.

RESULTS

From a total of 13524 pap smears done, 946 (7%) have shown precancerous lesions. 70% of these were high grade while 30% were low grade. These lesions were observed at all age from the range of 11 to 15 years. All women showing these lesions had had sexual intercourse. 30% of these lesions were noted among women who have had their first sexual intercourses between 10 and 15 years. 40% were observed among women who have had their first sexual intercourses between 16 and 18 years. 66% among women who have had their first delivery between 13 and 21 years. 92% are observed among women who have had more than five pregnancies, more than five parities; 54% among women who are married and 76% among bachelors and widows; 64% among women with low socioeconomical status; 9% among women with high socioeconomical status.

CONCLUSION

Many cameroonian women are prone to cervical cancer.