Is the nature of cervical carcinoma changing in young women?

Knowledge of cervical cancer among 25-54-year-old women in Beijing

The purpose of this study is to examine knowledge of cervical cancer and the relationship between knowledge of human papillomavirus (HPV) infection and cervical disease in a largely representative Beijing population. A questionnaire-based survey was conducted in a Beijing population sample of married women ages 25 to 54 years (n = 6,339), evaluating knowledge and relevant factors with regard to cervical cancer. Knowledge levels were low; only 52.5% (n = 3,328) of the respondents knew that cervical cancer can be detected in its early stage. Only 26.9% reported that human HPV infections were risk factors for cervical cancer. The level of knowledge was lower among older, with less education, less income, unstable profession, and non-Beijing Hukou women (all P < 0.01). An increasing level of knowledge may impact positively on intentions to participate in cervical cancer screening. Education schemes to improve knowledge of cervical cancer should be performed in a multimodel, multichannel method.

Prevalence of high-grade CIN following mild dyskaryotic smears in different age groups

OBJECTIVE

The new guidelines of the British Society of Colposcopy and Cervical Pathology suggest that women should be offered colposcopy after only one mildly dyskaryotic smear. This is expected to generate increased workload for the colposcopy clinics, at least in the short term. The main objective of this study was to estimate the incidence of high-grade cervical intraepithelial neoplasia (CIN) in women with mildly dyskaryotic smears and investigate whether there is any variation in different age groups. The rationale was to determine whether we could reduce the burden on colposcopy services by prioritizing the mild dyskaryotic referrals by age, as we hypothesized that high-grade CIN is less frequent in younger women.

METHODS

The study sample included all women who were referred for colposcopy with a cervical smear suggesting mild dyskaryosis (with or without koilocytosis) from April 2000 to March 2003.

RESULTS

We studied 510 women. They were divided into three age groups (<20, 20-25 and >25 years). The overall prevalence of high-grade CIN (CIN II and III) was 28.7%. The positive predictive value of a mildly dyskaryotic smear for high-grade CIN was similar in all groups.

CONCLUSIONS

Our results show that we are not in a position to prioritize our referrals by age group and reduce the initial pressure for colposcopies. We are also concerned that with the implementation of the new guidelines, a significant number of women <25 years will be carrying high-grade CIN for more than 5 years before they are first screened.

Young women, cervical intraepithelial neoplasia and human papillomavirus: risk factors for persistence and recurrence

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections (STIs) in young women. They can occur in one or multiple areas of the female genitalia. Usually, the vulva is the initial site of implantation for HPV. The purpose of our study is to evaluate the epidemiological aspects, incidence of single or multiple lesions in the lower genital tract, correlation between sexual behaviour and their localization and behaviour risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN) in a long-term follow-up among young women. We recruited 268 patients aged 11-21 years who previously had cytology and/or physical examination suspicious for HPV infection. The women were interviewed and asked information about lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. We considered individuals to be 'smokers' if they smoked more than five cigarettes/day. No specific data were recorded about oral contraception, nevertheless, no woman had used oral contraceptives (OCs) for more than 2 years. Young women included in the study were between the age of 12 and 21 years who had HVP lesions after entry examinations and had undergone no treatment for HPV lesions prior to entry. Other exclusion criteria relevant to this study included cervical excisional treatment prior to entry or later. Two hundred and thirty-four young women were included in our study group. Our diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy, directed biopsy and microcolpohysteroscopy. The treatment was performed with a LASER CO2 Coherent 400, model 451, with Zeiss photocolposcopy attachment. The finding that, among 126/234 (53.8%) adolescents using contraceptives, only 85 (36.3%) have used condom, the only barrier form of contraceptive effectively protecting against virus, shows a low awareness of the high risk for contracting HPV infection among young sexually active women. The sites most frequently affected in our study were vulva, perianus and perineum (194/234), 82.9% and the cervix (125/234), 53.4%. Vaginal lesions were detected only in 29/234 patients (12.3%). According to our data, in 161 patients, sexual habits, age at the first intercourse (P=0.68), frequency of intercourses (P=0.49) and number of lifetime partners (P=0.27) as well as age (P=0.26) play a role in transmission and incidence of HPV infection but not on the location of the lesions. This can be due to a coexistent clinical and subclinical multiple infection as well as a transmission via intercourse or from other sources, including tampons. Abnormal Pap test was related to HPV infection, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover, according to our data, cytology alone shows to be not suitable to exclude CIN (seven underestimated cases of CIN) and a closer correspondence were found between colposcopy and the result of histological sample after punch biopsy in CIN detection. More attention must be paid to psychological aspect of diagnoses and treatment among adolescents, more than older women as the high rate of patients lost shows in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. International data shows that only 12-45% of sexually active adolescent girls have obtained Pap smear screening. In our study, we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER CO2 surgery. Because the small sample of our study group, further analyses were required.

Characteristics of a group of adolescents undergoing loop electrical excision procedure (LEEP)

STUDY OBJECTIVE

To describe the sociodemographic characteristics of a cohort of adolescents undergoing loop electrosurgical excision procedure (LEEP) of the cervix, and to determine if LEEP is a safe and effective procedure for evaluation and treatment of high-grade squamous intraepithelial lesions (HSIL) of the cervix in adolescents.

SETTING

Case series of all adolescents who underwent LEEP between 1995 and 1997 at Children's Hospital, Boston, MA.

DESIGN

Medical and laboratory records were reviewed to assess baseline characteristics and the following outcomes: (1) LEEP pathology results, (2) postoperative complications, (3) pregnancy outcomes, (4) compliance with follow-up appointments, and (5) recurrence of disease over a 12- to 37-month period.

PARTICIPANTS

Thirty-five adolescents underwent LEEP. The mean age of the adolescents at the time of LEEP was 17.9 +/- 1.5 yrs.

RESULTS

The mean interval between coitarche and LEEP was 3.69 +/- 2.09 yrs. On preoperative colposcopy, 28 (80%) had HSIL on biopsy, 3 (8.6%) had HSIL on Pap smear with a discordant biopsy demonstrating low-grade squamous intraepithelial lesion (LSIL), 1 (2.9%) had a persistent LSIL, 2 (5.6%) had diffuse LSIL with an unsatisfactory colposcopy, and 1 (2.9%) had a HSIL Pap smear with a normal biopsy. LEEP specimen histopathology results were: HSIL in 19 (54%), LSIL in 10 (29%), SIL difficult to grade in 3 (9%), and no residual disease in 3 (9.0%). Postoperative complications were bleeding in 2 (5.7%), pain in 1 (2.9%), vaginal discharge in 1 (2.9%), cervicitis in 3 (8.6%), and endometritis in 2 (5.7%). Fourteen pregnancies were diagnosed after LEEP; no spontaneous abortions occurred. Mean follow-up period was 21.1 +/- 9.4 months. Compliance with follow-up appointments was 51% in the first 12 months post-LEEP and 26% in the second 12 months post-LEEP. Of the 28 patients followed for 12 months or more, there was one recurrence of HSIL confirmed by colposcopy and biopsy.

CONCLUSIONS

Outcome and complications of LEEP in adolescent females are similar to those reported in larger series of adult women. LEEP appears to be a safe and effective procedure for the evaluation and treatment of HSIL of the cervix in adolescents, but additional long-term data are needed.

An update on human papillomavirus infection and Papanicolaou smears in adolescents

Human papillomavirus infection is one of the most common sexually transmitted infections in young women, and may lead to clinical sequelae such as anogenital condylomata and cervical squamous cell carcinoma. Recent data on the biology and natural history of HPV infection in adolescents will have important implications for the development of adolescent-specific protocols for cervical cancer screening and for follow-up of abnormal cytology.

Survival of patients with adenocarcinoma of the uterine cervix in western Sweden

Survival in adenocarcinoma of the uterine cervix varies between different reports. In our study the patients have been treated in a similar way as those with squamous cell carcinoma. One hundred twenty-one adenocarcinomas were diagnosed between 1987 and 1994 in the West Sweden Health Care Region. One hundred of the patients with adenocarcinoma were treated at Sahlgrenska University Hospital and studied retrospectively. The median age was 54 years (range 27-91). Histopathologic differentiation was relatively evenly distributed between well (34%), intermediately (38%), and poorly differentiated (28%). All FIGO stages were represented, but stage I predominated (65%). Depending mainly on tumor stage and age, the patients had either surgery, surgery + radiotherapy, or radiotherapy only. In our study, the five-year survival for adenocarcinoma was 64% and for squamous/adenosquamous carcinoma was 66% (NS). The five-year survival for different stages of adenocarcinomas was for stage I 86%, stage II 38%, stage III 23%, and stage IV 0%, the difference between stage I and stage II being highly significant. Treated in a similar way, the five-year survival for adenocarcinoma is equal to that for squamous/adenosquamous carcinoma in our study.

MIB 1 immunostaining in cervical carcinoma of young patients

OBJECTIVE

In the present study, we assessed whether biologic characteristics of tumors in young patients differ from those observed in older patients with the same clinical and histologic characteristics, but ranging in age from 50 to 70 years. The hypothesis to be verified was whether cervical carcinoma in young patients presented an increased proliferative activity which might explain more aggressive behavior.

MATERIALS AND METHODS

Locally advanced cervical carcinoma tumor samples were obtained from our series of patients, maximum age 40 years, and immunohistochemically evaluated by monoclonal MIB 1 antibody (Immunotech, Marseille Cedex, France) on microwave-oven-processed Formalin-fixed paraffin-embedded tissue. Positive staining was expressed as a percentage of positive cells per 10(3) counted neoplastic cells for each case. For each young patient, a control was selected among patients aged >/=50 years (range 50-70) matched for stage, tumor size, histologic type and grading, and lymphvascular invasion.

RESULTS

Fourteen of 73 patients (19.2%) with stage I and IIa cervical carcinoma who underwent primary radical surgery at our Institute between 1986 and 1994 were aged </=40 years. The MIB 1 index was significantly higher in young patients with respect to the older group (mean +/- standard deviation, 61.6 +/- 16.3% and 45.2 +/- 12.2%, with P = 0.006).

CONCLUSIONS

Although any conclusions from this study need to be tempered because of the small number of patients involved, locally advanced cervical carcinomas present in young patients showed a more aggressive biologic behavior, expressed by a higher cell proliferation index.

Follow-up of abnormal Papanicolaou smears in a hospital-based adolescent clinic

STUDY OBJECTIVE

To present data on the spectrum of abnormal Papanicolaou (PAP) smears in adolescents and to determine factors that influence compliance with recommendations to return for repeat PAP smears or for colposcopic examination.

DESIGN

Retrospective chart review with follow-up telephone calls to patients who did not follow recommendations for colposcopy.

SETTING

Adolescents receiving health care in a hospital-based adolescent clinic.

PARTICIPANTS

Patients with abnormal PAP smears between July 1, 1994 and June 30, 1995.

MAIN OUTCOME MEASURES

Compliance with follow-up for abnormal PAP smears including referral to the colposcopy clinic, and the results of repeat PAP smears and colposcopy.

RESULTS

Of 888 adolescents undergoing PAP smear evaluation 119 (13.4%) had an abnormal PAP smear during the study year (index PAP). The results of the index PAP were 97 (81.5%) atypia and 22 (18.5%) squamous intraepithelial lesion low grade (SIL LG). The index PAP was the first abnormal PAP smear for 92 of the patients (77%); 27 had one or more previous abnormal PAP smears (18 atypia, 7 SIL LG, 2 SIL high grade [HG]), and 13 had been referred for colposcopy in the past. For 76 of 92 patients with atypia on index PAP (84%), the index PAP was the first abnormal PAP smear. Of these 76 patients, 51 had a second PAP smear: 27 (53%) were normal, 13 (25%) atypia, and 11 (22%) SIL LG. Sixty patients were referred to the colposcopy clinic, but only 37 actually kept the colposcopy appointment despite outreach. The only significant factor for obtaining colposcopy was a visit to the Adolescent Clinic after notification of the abnormal PAP smear result and before the colposcopy appointment; 79% of those who had a visit obtained colposcopy compared with 45% of those who did not have such a visit (p = 0.007). There were no significant differences by race, insurance status, age, PAP smear result, previous referral for colposcopy, or number of reminders with compliance with recommendations for repeat PAP smears or colposcopy.

CONCLUSIONS

Although a sizable proportion of adolescents with abnormal PAP smears have significant pathology on repeat PAP smears, adolescents with abnormal PAP smears have a high failure rate in keeping appointments for follow-up PAP smears and colposcopy. Interventions that target all adolescents with abnormal PAP smears need to be designed and tested to aid follow-up.

Changing incidence of invasive adenocarcinoma of the uterine cervix in East Anglia

OBJECTIVE

To determine trends in incidence of invasive adenocarcinoma of the uterine cervix in East Anglia.

METHODS

Cervical cancer incidence data for both squamous cell carcinomas and adenocarcinomas were obtained from the East Anglian Cancer Registry for the period 1971-94. Similar data were obtained for England and Wales. European age standardised rates (ASRs) were used for comparisons.

RESULTS

The mean incidence (ASR) of cervical adenocarcinoma was 0.85 per 10(5) in 1971-76, rising to 2.54 per 10(5) in 1989-94. There has been a marked age shift, with the main increase in incidence occurring in younger women aged 30-39. The mean incidence (ASR) of squamous cell carcinoma of the cervix has decreased from 9.78 to 8.74 per 10(5) over the periods 1971-76 and 1989-94. Again there has been an age shift, moving from a single incidence peak in the 45-59 age band in earlier years to incidence peaks in both the 30-39 and 55-69 age bands in more recent years. Similar trends were noted when data for England and Wales were analysed. Birth cohort analyses show that both tumours are occurring progressively earlier (about five years earlier in each five year birth cohort).

CONCLUSION

Although the overall incidence of cervical carcinoma is declining, this study has shown an increased incidence of cervical adenocarcinoma, particularly in the younger age groups. In future it would seem advisable to publish separate incidence and mortality data for squamous cell carcinoma and adenocarcinoma of the uterine cervix. All practitioners involved in the cervical cancer screening programme would then be aware of the very real significance of this tumour.