Is cervical cytology screening of teenagers worthwhile?

Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda

BACKGROUND

Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.

METHODS

In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.

RESULTS

Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.

CONCLUSION

Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.

Cervical screening: time to change the policy

1. In 1991, the "organised approach to preventing cancer of the cervix" recommended Pap smears every two years for women aged 18-70 years who have ever been sexually active. 2. The two-year interval was a compromise step towards the scientifically supported three-year interval, as many influential groups were strongly attached to annual screening. When other components of the organised approach were in place, the policy was to be reviewed. 3. Since the safeguards in the "organised approach" have been proven effective, it is appropriate to change the policy to recommend a three-year interval. Increasing the interval would allow more resources to be allocated to enrolling women currently underscreened and to evaluating and improving the program. 4. The age of commencing smears could also be reconsidered to reflect the balance of potential benefits and harm in young women, for whom cancer is very rare but follow-up investigation common. 5. If consensus is not reached within the profession, an evidence-based decision may need to be made at the political level.

Pap smear screening in an urban STD clinic. Yield of screening and predictors of abnormalities

BACKGROUND

Pap smear screening studies in STD clinics have reported high rates of squamous intraepithelial lesions (SIL); however, there are limited data on levels of unsatisfactory smears of characteristics associated with cytologic abnormalities.

GOAL

To assess the yield to Pap smear screening in an STD clinic and to evaluate the rates of and risk factors for atypia, low-grade SIL (LSIL), and high-grade SIL (HSIL).

STUDY DESIGN

A chart review of the clinic records of women undergoing Pap smear screening between 1991 and 1994 was conducted. Results were assessed from two different screening protocols, the first using a Dacron swab to obtain the endocervical sample and the second using a cytobrush.

RESULTS

Of 2034 Pap smears, 1313 (64.6%) were negative, 202 (9.9%) were unsatisfactory, 257 (12.6%) were atypical, 211 (10.4%) had LSIL, and 51 (2.5%) had HSIL. With the change to the cytobrush protocol, the rate of unsatisfactory smears decreased from 14.4% to 3% (p < 0.001), atypia increased from 10% to 16.7% (p < 0.001), and HSIL rose from 1.7% to 3.7% (p < 0.001). By multivariate analysis, atypia was associated with genital warts (odds ratio (OR) 1.53, 95% confidence interval (CI): 1.16-2.02); LSIL with younger age (p < 0.001, for trend), black race (OR 1.51, 95% CI: 1.08-2.10), genital warts (OR 1.81, 95% CI: 1.33-2.47), and an abnormal appearance of the cervix on examination (OR 2.49, 95% CI: 1.85-3.35); and HSIL with a previous abnormal Pap smear (OR 2.48, 95% CI: 1.08-2.10). Overall, abnormality rates were significantly higher in adolescents (35.5%) than older women (21.7%) (p < 0.01).

CONCLUSIONS

Obtaining satisfactory Pap smears among women undergoing screening in an STD clinic is feasible and cytologic abnormalities are common. These results continue to support the need for Pap smear screening in STD clinics, but the high rates in adolescents, a group in whom the natural history of cytologic abnormalities has not been well-defined, raise questions about the need to develop age-appropriate screening and management strategies.

Colposcopic and cytologic findings among adolescents referred to two urban teaching hospitals

STUDY OBJECTIVE

To determine colposcopic findings among adolescents and to determine compliance with management recommendations.

DESIGN

Retrospective review of colposcopy logs and patient charts.

SETTING

Two urban resident colposcopy clinics.

PARTICIPANTS

Low-income, predominantly minority girls 16 years of age or younger referred for evaluation of abnormal cervical cytology.

INTERVENTION

Colposcopy with directed biopsy.

MAIN OUTCOME MEASURES

Histologic findings in colposcopic biopsies and compliance with management recommendations.

RESULTS

Of 62 adolescents evaluated, 17 (27%) had biopsies showing atypia or koilocytosis and 13 (21%) had dysplasia, with grade 2 cervical intraepithelial neoplasia (CIN 2) in 5 (8%). No biopsy showed CIN 3 or invasive cancer. None of 31 endocervical curettings contained dysplasia. Forty-one adolescents (66%) failed to comply with recommendations for surveillance or treatment.

CONCLUSIONS

The prevalence of dysplasia among adolescents referred for colposcopy is substantial, and better strategies are needed to ensure proper follow-up.