Screen-detected invasive cervical carcinoma and its clinical significance during the introduction of organized screening

Predictors factors of the absence of high-grade intraepithelial lesion in excisional therapy specimen

OBJECTIVES

To identify predictive factors of the absence of high-grade intraepithelial lesion (HGSIL) in cervical excisional therapy specimen.

METHODS

Data from 835 women who underwent excisional therapy for a cervical intra epithelial lesion at the department of Gynaecology from two university hospitals, between January 2015 and December 2020 were reviewed. Demographic data, referral cytology, colposcopic findings, results of cervical biopsy and endocervical curettage were retrieved. Primary outcome was the absence of HGSIL on cervical excisional specimen analysis defined by the identification of no intraepithelial lesion or of low-grade lesion only.

RESULTS

The absence of HGSIL on specimen was observed in 137 (16.4%) cases. Three factors were identified to have a significant and independent impact on the probability of the absence of HGSIL on specimen: age higher than 40 years (aOR: 1.8; 95%CI: 1.1-3.0; p=0.024), a small abnormal transformation zone (TZ) (aOR: 2.3; 95%CI: 1.4-3.7; p=0.001) and the result of the cervical biopsy at the time of colposcopic assessment not showing HGSIL (aOR: 8.6; 95%CI: 4.7-15.5; p < 0.001). No significant impact of the referral cytology nor of the colposcopic impression were observed.

CONCLUSION

Although the result of cervical biopsy performed at the time of colposcopic assessment is the key risk factor for the absence of HGSIL on excisional specimen, age over 40 and a small abnormal TZ are the two other identified risk factors. Practitioners should consider these findings when deciding for excisional therapy.

Demand for Cancer Screening Services: Results From Randomized Controlled Discrete Choice Experiments

OBJECTIVES

Low uptake of cancer screening services is a global concern. Our aim was to understand factors that influence the screening decision, including screening and treatment subsidies and a gain-frame message designed to present screening as a win-win.

METHODS

We analyzed preferences for mammography and Pap smear among women in Singapore by means of discrete choice experiments while randomly exposing half of respondents to a gain-framed public health message promoting the benefits of screening.

RESULTS

Results showed that the message did not influence stated uptake, and given the levels shown, respondents were influenced more by treatment attributes, including effectiveness and out-of-pocket cost should they test positive, than by screening attributes, including the offer of a monetary incentive for screening. Respondents also underestimated the survival chances of screen-detected breast and cervical cancers.

CONCLUSIONS

Combined, these findings suggest that correcting misconceptions about screen-detected cancer prognosis or providing greater financial protection for those who test positive could be more effective and more cost-effective than subsidizing screening directly in increasing screening uptakes.

Cervical cancer in women under 25 years of age in Queensland, Australia: To what extent is the diagnosis made by screening cytology?

INTRODUCTION

The current Australian National Cervical Screening Program (NCSP) involves biennial, cytology-based screening of women from the age of 18 years. From December, 2017 this will change to a five-yearly human papilloma virus-based screening commencing at age 25. There is some concern that the new program may delay the opportunistic detection of cervical cancers in women under 25 years.

AIM

(1) To review all cases of invasive cervical cancer in Queensland women under the age of 25 over the last 28 years. (2) To determine symptoms and screening history prior to diagnosis.

METHODS

A retrospective cohort study was undertaken at the Queensland Centre for Gynaecological Cancer (QCGC) and the Queensland Cancer Registry (QCR) of all women aged between 13 and 25 years diagnosed with cervical cancer in Queensland between 1984 and 2012. Demographic data and symptoms prior to diagnosis were extracted from the QCGC and QCR databases.

RESULTS

A total of 56 women aged 13-25, were diagnosed with cervical cancer and treated at the QCGC between 1984 and 2012. The commonest reason for the diagnosis of cancer was investigation of abnormal symptoms (n = 22, 39%) rather than routine Pap smear abnormalities (n = 15, 26%).

CONCLUSIONS

Consistent with the world literature, there is a very low incidence of cervical cancer in women under 25 years of age, irrespective of the age of commencement of screening, or the screening interval. Our study lends some support to the proposed commencement age of 25 years in the new NCSP.

Poor Cervical Cancer Screening Attendance and False Negatives. A Call for Organized Screening

Objective

The objective of this study was to describe prior negative screening history and symptoms around the time of diagnosis of incident cervical cancer (CC) cases diagnosed between 2000 and 2010 within the Asturias public health system.

Methods

Records from 374 women diagnosed with CC between 2000 and 2010 from all public hospitals in Asturias were retrieved. Clinical information, FIGO stage and all previous cytological data were extracted from clinical and histopathological records. Proportional differences were assessed using chi-square tests. Logistic regression analysis was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Inter-observer agreement in cytology was checked by comparing concordance values using k-statistics.

Results

No prior screening history was recorded in 60.7% of CC cases and its absence increased with age and advanced stage. Advanced stage (e.g., ≥ II) at diagnosis was associated with age (>50 years) and adenocarcinoma (ADC) compared to younger women and those with a squamous cell carcinoma (SCC). False negative smears were identified in 27.1% of women with CC (ADC 52.6% vs. SCC 16.2%, p<0.05).

Conclusions

Absence of prior screening history was common among CC cases. Organized actions to reduce “under screening” and the use of highly sensitive HPV-based tests could be useful strategies in reducing the burden of CC in Asturias.

A randomized trial of buffered versus nonbuffered lidocaine with epinephrine for cervical loop excision

OBJECTIVE

Our study evaluated whether buffering reduces pain from lidocaine injection for loop electrosurgical excisional procedures (LEEPs) of the cervix when compared to unbuffered lidocaine.

METHODS

Women undergoing outpatient LEEPs were randomized to receive either buffered or unbuffered lidocaine. Participants, caregivers, and statisticians were blinded to treatment allocation. Pain was categorized as injection, procedure, or cramping pain. Severity of pain was reported using a Likert visual analog scale and compared using Mann-Whitney tests.

RESULTS

Twenty-eight subjects received buffered lidocaine and 24 subjects received unbuffered lidocaine. The 2 groups were similar in regard to age, race, previous LEEP, anesthetic volume used, and loop size. Mean scores were similar between the nonbuffered and buffered groups for injection pain (25 vs 19, p = .13), procedure pain (27 vs 19, p = .08), and cramping pain (19 vs 18, p = .86).

CONCLUSIONS

Pain scores with subepithelial lidocaine plus epinephrine for LEEP are low and are not significantly reduced by buffering the anesthetic.

Screening test results associated with cancer diagnoses in 287 women with cervical squamous cell carcinoma

CONTEXT

The limitations of newer cervical screening tests are still being studied.

OBJECTIVE

To investigate those limitations, we conducted a retrospective review of 287 cases of cervical squamous cell carcinoma (SCC).

DESIGN

A search through 5 years of records identified 287 women with cervical SCC diagnoses. Clinical history, histopathology, and liquid-based cytology (ThinPrep) and Hybrid Capture 2 (HC2) high-risk human papillomavirus (HPV) results were documented. Polymerase chain reaction HPV tests were performed on SCC tissues with prior negative HC2 results.

RESULTS

Of 287 women, 156 (54.4%) had abnormal cytology results, and 75 (26.1%) had abnormal clinical findings triggering tissue diagnoses of SCC. Among 156 patients with abnormal Papanicolaou (Pap) test results, more-seriously abnormal Pap test results were reported in 142 women (91.1%). Among 31 women with Pap and HC2 HPV cotesting within 1 year of SCC diagnoses, 28 (90%) were Pap⁺/HPV⁺, 2 (15.5%) were Pap⁺/HPV⁻, and 1 (3%) was Pap⁻/HPV⁻. Two of 3 women with negative HC2 results before SCC diagnosis had abnormal Pap results; 1 had negative Pap reports with questionable lesional cells mimicking atrophy. In all 3 cases of SCC with negative HC2 results, HPV-18 was detected; in 2 cases (66%), HPV-16 was also detected.

CONCLUSIONS

Although abnormal cytology preceded most SCC diagnoses, about one-third of patients were referred for diagnostic testing because of clinical suspicion alone. Among 31 SCC cases with liquid-based cytology and high-risk HPV cotest results less than 1 year before SCC diagnoses, 2 patients (6.5%) had Pap⁺/HPV⁻ results, and 1 patient (3.2%) had Pap⁻/HPV⁻ results. Polymerase chain reaction detected high-risk HPV DNA in tumor tissues of 3 SCC cases with recent HC2⁻ results.

Review of negative and low-grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia

OBJECTIVE

The purpose of the study was to perform a national review of negative, low-grade and inadequate smears reported during the latest screening period before cervical cancer diagnosis in 2006, after the first 3 years of the screening programme.

METHODS

Among 162 new cervical cancer cases there were 47 (29%) without previous cytology, 47 (29%) with one high-grade smear prior to diagnosis and 68 (42.0%) with at least one previous negative, low-grade, atypical or inadequate smear 1-40 months before diagnosis. Of the latter 68 cases, 37 patients with 59 smears (together with 118 control slides) were included in the review as 31 had smears reported at laboratories no longer operating. Findings were related to the last cytology report before diagnosis as well as to histological type and stage of the cancer.

RESULTS

In our study group, 19 (51%) of 37 patients had squamous cell carcinoma, 15 (41%) adenocarcinoma and 3 (8%) adenosquamous carcinoma, compared with 121 (75%), 26 (16%), 12 (7%), respectively, and 3 (2%) other types, for all carcinomas. Twenty-one of 37 women also had high-grade cytology prior to diagnosis of cancer. Women with previous cytology (with or without recent high-grade smears) were more likely to have stage I cancers than those without cytology (P < 0.0001). The expert group upgraded 17/33 smears in the patients with squamous carcinomas, which was more than in those with adeno- and adenosquamous carcinomas (5/24, P < 0.05).

CONCLUSION

As expected, a higher proportion of smears preceding adenocarcinomas were true negative. Under-diagnosed smears were not related to cancer stage or last cytology report before diagnosis.

Screening history of women with invasive cervical cancer in north-east Italy

OBJECTIVES

To describe screening histories of women with invasive cervical cancer (ICC) in Friuli Venezia Giulia, after the introduction of organized screening, in order to identify possible reasons undermining prevention of ICC. To investigate associations between screening histories in relation to women's survival and tumor characteristics, with a focus on organized and opportunistic screenings.

STUDY DESIGN

438 women, diagnosed with ICC between 1999 and 2005, were identified using the regional Cancer Registry. Cytological and histopathological information were obtained through regional health databases. Associations between different screening histories and characteristics of women and their tumors were evaluated by means of odds ratios (OR) and corresponding 95% confidence intervals (CI), through multinomial logistic regression models adjusted for age; death risks were estimated by computing hazard ratios (HR) with 95% CI, using Cox models adjusted for age, tumor stage, and histology.

RESULTS

165 (38%) women with ICC had no Pap smears: 71 (16%) never attended the organized screening despite invitation; 69 (16%) were never invited because they were above 64 years of age; and 25 (6%) were yet to be invited. Conversely, 273 (62%) women underwent screening: 141 women (32%) had opportunistic screening; 132 (30%) women attended the organized program. A total of 193 (44%) women had ICC detected at screening. Compared to women with ICC who had never been screened, those screened within the organized program were more often at stage IA (46%), were seldom at stage II or higher (OR=0.3, 95% CI: 0.1-0.6, vs. IB), and showed a lower risk of death (HR=0.6, 95% CI: 0.3-1.0).

CONCLUSIONS

In Friuli Venezia Giulia, the lack of screening among older women and of compliance with organized programs among women in the target population are the main limitations in cervical cancer secondary prevention. Our findings indicate that participation in organized screening has a beneficial effect in terms of down-staging and improved survival as compared to both absence of screening and opportunistic screening.