Screening for cervical intraepithelial neoplasia in north east Scotland shows fall in incidence and mortality from invasive cancer with concomitant rise in preinvasive disease

Patient survival prediction in locally advanced cervical squamous cell carcinoma using MRI-based radiomics: retrospective cohort study

Cervical cancer is a major health concern for women, ranking as the fourth most common cancer and a significant cause of cancer-related deaths worldwide. To enhance prognostic predictions for locally advanced cervical squamous cell carcinoma, we conducted a study utilizing radiomics features extracted from pretreatment magnetic resonance images. The goal was to predict patient survival and compare the predictive value of these features with clinical traits and the 2018 International Federation of Obstetrics and Gynecology (FIGO) staging system. In our retrospective cohort study, we included 500 patients with confirmed cervical squamous cell carcinoma ranging from FIGO stages IIB to IVA under the 2018 staging system. All patients underwent pelvic MRI with diffusion-weighted imaging before receiving definitive curative concurrent chemoradiotherapy. The results showed that the combination model, incorporating radiomics scores and clinical traits, demonstrated superior predictive accuracy compared to the widely used 2018 FIGO staging system for both progression-free and overall survival. Age was identified as a significant factor influencing survival outcomes. Additionally, primary tumour invasion stage, tumour maximal diameter, and the location of lymph node metastasis were found to be important predictors of progression-free survival, while primary tumour invasion stage and lymph node metastasis position individually affected overall survival. During the follow-up period, a portion of patients experienced disease-related deaths or tumour progression/recurrence in both sets. The radiomics-score significantly enhanced prediction ability, providing valuable insights for guiding personalized therapy approaches and stratifying patients into low-risk and high-risk categories for progression-free and overall survival. In conclusion, our study demonstrated the potential of radiomics features as a valuable addition to existing clinical tools like the FIGO staging system, offering promising advancements in managing locally advanced cervical squamous cell carcinoma.

Exposure Definition in Case-Control Studies of Cervical Cancer Screening: A Systematic Literature Review

The first step in evaluating the effectiveness of cervical screening is defining exposure to screening. Our aim was to describe the spectrum of screening exposure definitions used in studies of the effectiveness of cervical screening. This systematic review included case-control studies in a population-based screening setting. Outcome was incidence of cervical cancer. Three electronic databases were searched from January 1, 2012 to December 6, 2018. Articles prior to 2012 were identified from a previous review. The qualitative synthesis focused on describing screening exposure definitions reported in the literature and the methodologic differences that could have an impact on the association between screening and cervical cancer. Forty-one case-control studies were included. Six screening exposure definitions were identified. Cervical cancer risk on average decreased by 66% when screening exposure was defined as ever tested, by 77% by time since last negative test, and by 79% after two or more previous tests. Methodologic differences included composition of the reference group and whether diagnostic and/or symptomatic tests were excluded from the analysis. Consensus guidelines to standardize exposure definitions are needed to ensure evaluations of cervical cancer screening can accurately measure the impact of transitioning from cytology to human papillomavirus-based screening and to allow comparisons between programs.

Respective prevalence of high-risk HPVgenotypes in cervical neoplasia in Senegal

OBJECTIVES

With the perspective of prophylactic vaccination against high-risk human papillomavirus (HPV), we analyzed the viral epidemiology of cervical neoplasia in Senegal.

METHODS

All patients were treated at the Institut Joliot Curie du Cancer in Dakar. HPV genotypes were characterized using a real-time polymerase chain reaction-based approach and sequencing.

RESULTS

Histologically, there were 224 invasive carcinomas, 17 high-grade intraepithelial neoplasia (CIN), and five undetermined histologies. Molecular analysis was conclusive in 241 cases. HPV DNA was found in 207/241 (85.9%) cases while 34/241 (14.1%) remained HPV negative. There was one single genotype in 127/207 (61.4%) cases and several in 80/207 (38.6%) corresponding to 308 genotypes identified. Viral genotyping found HPV16 in 175 (56.8%) cases, HPV18 in 45 (14.6%), HPV45 in 40 (13.0%), HPV58 in 35 (11.4%), HPV33 in 6 (2.0%), HPV35 in 3 (1.0%), HPV31 in 2 (0.6%), HPV39 and HPV56 in one (0.3% each).

CONCLUSION

Our analysis showed that 98.4% of the HPV-positive cases were associated with viral genotypes covered by the 9-valent HPV vaccine. However, 14.1% of cases remained HPV negative. Therefore, prophylactic vaccination using a 9-valent vaccine should dramatically reduce the incidence of HPV-associated neoplasia but the detection and treatment of CIN remain necessary for the optimal prevention of cervical cancer.

Changes in the incidence of cervical tumours by disease stage in a cytology-based screening programme

OBJECTIVES

To report changes in incidence of cervical tumours by disease stage, following the introduction of an organized cytology-based screening programme.

METHODS

An intention-to-screen study of a cytology-based screening programme targeting 1,219,000 women aged 25-64 in northern Italy was carried out. Based on the previously reported trend in total incidence of cervical cancer, the study period 1995-2014 was divided into 1995-1996 (pre-screening, or reference, years), 1997-1998 (screening implementation phase), 1999-2006 (transition phase, when incidence decreased), and 2007-2014 (steady-state phase, when incidence stabilized again). Tumour stage was categorized as preinvasive (cervical intraepithelial neoplasia grade 3 (CIN3) and adenocarcinoma in situ), early (pT1a), advanced (pT1b or greater, ypT), and unknown (pT1 not otherwise specified, pTx, missing information). Average annual incidence rates observed in each phase were compared with the expected (reference) rates, using the incidence rate ratio, calculated with a Poisson regression model.

RESULTS

In the steady-state phase, incidence rate ratios were: CIN3, 1.55 (95% confidence interval, 1.41-1.70); early-stage squamous carcinoma, 0.49 (0.36-0.67); advanced-stage squamous carcinoma, 0.44 (0.33-0.57); unknown-stage squamous carcinoma, 0.69 (0.48-0.99); adenocarcinoma in situ, 1.44 (0.72-2.88); early-stage adenocarcinoma, 2.65 (0.82-8.53); advanced-stage adenocarcinoma, 1.03 (0.56-1.91); and unknown-stage adenocarcinoma, 0.46 (0.23-0.92).

CONCLUSIONS

After stabilization, changes in incidence by tumour stage included a 55% increase for CIN3 and a 50-55% decrease both for early- and advanced-stage squamous carcinoma, but no significant changes for glandular tumours. These data will serve to quantify the incremental impact of the implementation of human papillomavirus-based screening, introduced in 2015.

Clinicopathological Characteristics of Atypical Glandular Cells Determined by Cervical Cytology in Japan: Survey of Gynecologic Oncology Data from the Obstetrical Gynecological Society of Kinki District, Japan

BACKGROUND

The purpose of this study was to clarify the clinicopathological characteristics of, and the clinical approach used to identify, atypical glandular cells (AGCs) in Japan based on cervical cytology screening.

OBJECTIVES

This study included 1,254 patients with AGCs who underwent cervical cytology.

METHOD

Data from patients with AGCs were used to examine the practical management of AGCs and the histological results.

RESULTS

The incidence of AGCs was 0.20% (1,254/614,791). The 1,254 AGC cases included 859 endocervical cells not otherwise specified (NOS), 3 glandular cells NOS, 91 endocervical cells favor neoplasia (FN), and 301 atypical endometrial cells (AEMCs). Among the 1,254 AGC patients, the histological diagnosis was benign in 666 (53.1%), cervical intraepithelial neoplasia (CIN) 1 in 60 (4.8%), CIN2 in 31 (2.5%), CIN3 in 52 (4.1%), squamous cell carcinoma in 19 (1.5%), adenocarcinoma in situ in 39 (3.1%), cervical adenocarcinoma in 106 (8.5%), endometrial carcinoma in 209 (16.7%), ovarian cancer in 26 (2.1%), other malignancy in 4 (0.3%), and other under follow-up in 42 (3.3%). When the 1,254 AGC patients were divided into three medical intervention degrees according to histology, AGC-NOS, AGC-FN, and AEMC required no medical intervention in 78.7, 13.2, and 25.9% (678, 12, and 78) of the patients, cervical cone resection in 13.0, 9.9, and 0.3% (112, 9, and 1) of the patients, and radical laparotomy for invasive cancer in 8.3, 76.9, and 73.8% (72, 70, and 222) of the patients, respectively.

CONCLUSIONS

Our histological results supported the medical interventions applied for AGC diagnosis and treatment. AGC cases require careful histological evaluation.

Estimating the impact of an organised screening programme on cervical cancer incidence: A 26-year study from northern Italy

The impact of the organised cervical cancer (CC) screening programmes implemented in Europe since the 1990s has been insufficiently evaluated. We investigated the changes in CC incidence following the introduction of a screening programme in the Emilia-Romagna Region (northern Italy). The study period was 1988-2013. The programme, targeting women aged 25-64 years (1,219,000 in 2018), started in 1998. The annual incidence rates that would be expected in 1998-2013 in the absence of screening were estimated, first, by analysing the annual rates in 1988-1997 with a log-linear model and, second, by analysing the annual rates in 1988-2013 with an age-period model in which the period effect was enforced to be linear. Cervical adenocarcinoma incidence trend over the entire period was used to validate both estimates. Observed annual rates were compared to the two series of expected ones with the incidence rate ratio (IRR). Incidence remained stable during 1988-1997, peaked in 1998 and then decreased until 2007, when it stabilised. The two series of expected rates were virtually coincident and their trends roughly paralleled the stable adenocarcinoma incidence trend. After 2007, the median IRR was 0.60 (95% confidence interval, 0.45-0.81) based on the log-linear model and 0.58 (95% confidence interval, 0.34-0.97) based on the age-period model. Thirty-six to seventy-five CC cases were prevented annually for an average annual frequency of 6.5 per 100,000 women in the target population. In summary, consistent circumstantial evidences were obtained that the organised screening programme brought about a 40% reduction in annual CC incidence after 10 years.

Trends in the Prevalence of Cervical Intraepithelial Neoplasia Grade 3 in the District of Florence, Italy

Aims and background

The objective of this study was to investigate the detection rate of cervical intraepithelial neoplasia grade III (CIN 3) in previously unscreened women, in order to reveal trends over time in the prevalence of CIN 3 in the District of Florence, where a population-based screening for cervical cancer has been going on since 1973.

Study design

We considered the women, recorded in the computerized archives of CSPO, who had had no pap test for at least 10 years. Trends of CIN 3 (histologically proven) were analyzed within age groups; the effect of age, cohort and period were considered by means of a Poisson regression model.

Results

A total of 648 cases of histologically proven CIN 3 were detected in the study period. The detection rates of CIN 3 increased steadly within age groups over birth cohort and calendar period simultaneously. The Poisson regression analysis showed that only the model with age + time trend was statistically significant.

Conclusions

Although several biases should be taken into account, the analysis seemed to indicate a real increase in CIN 3 prevalence. An increase in frequency of precancerous lesions for cervical cancer in more recent birth cohorts supports the need to keep screening coverage and efficiency as high as possible.

Programmed death-1 (PD-1) expression in cervical intraepithelial neoplasia and its relationship with recurrence after conization

OBJECTIVE

Impaired local cellular immunity contributes to persistent human papillomavirus (HPV) infection and development of cervical intraepithelial neoplasia (CIN). Programmed death-1 (PD-1) and its ligands PD-ligand-1 (L1) and PD-L2 are negative regulators of T cell activity in various cancers, but few studies exist. The aim of this study was to determine the clinicopathologic and immunologic parameters (PD-1, PD-L1, and PD-L2) related to the persistence/recurrence of CIN after conization.

METHODS

Medical records of 652 patients diagnosed with CIN and underwent conization were reviewed. The associations between clinicopathologic parameters (e.g., age, parity, initial HPV load, etc.) and persistence/recurrence of CIN were analyzed. Expression of PD-1, PD-L1, and PD-L2 was assessed on 100 conization specimens by immunohistochemistry (IHC) in women matched for propensity-score (50 with persistence/recurrence and 50 without).

RESULTS

Initial HPV load (>1,000 relative light unit) and positive margin were shown to be significantly associated with CIN persistence/recurrence (p=0.012 and p<0.001, respectively). Multivariate analysis showed that margin status was an independent predictor of persistence/recurrence (hazard ratio=8.86; 95% confidence interval=1.67-16.81; p<0.001). On IHC analysis, none of the patients expressed PD-L1. PD-1+ T cells were observed in 25 of 100 patients. Also, PD-1+ T cells were significantly correlated with increasing grade of CIN (p=0.031). In addition, patients with persistence/recurrence had increased expression of PD-1 compared with those without (36% vs. 14%, respectively; p=0.020). Although PD-L2 expression did not differ between 2 groups, it was significantly higher in patients with high-grade CIN compared to low-grade (34.7% vs. 12%, respectively; p=0.041).

CONCLUSION

Positive surgical margin and expression of PD-1+ T cells were associated with CIN persistence/recurrence after conization.

Evaluation of p16/Ki-67 dual-stained cytology as triage test for high-risk human papillomavirus-positive women

The aim of this study was to evaluate the clinical utility of p16/Ki-67 dual staining, for the identification of CIN in high-risk HPV-positive women from a non-responder screening cohort. P16/Ki-67 dual staining, Pap cytology, and HPV16/18 genotyping were performed on physician-taken liquid-based samples from 495 women who tested high-risk HPV positive on self-sampled material (PROHTECT-3B study). Different triage strategies involving p16/Ki-67 dual staining were evaluated for sensitivity, specificity, and predictive value for ≥CIN2 and ≥CIN3, and compared to Pap cytology with a threshold of atypical cells of undetermined significance. Centrally revised histology or an adjusted endpoint with combined high-risk HPV negative and cytology negative follow-up at 6 months was used as gold standard. Pap cytology (threshold atypical cells of undetermined significance) triage of high-risk HPV-positive samples showed a sensitivity of 93% (95% confidence interval: 85-98) with a specificity of 49% (95% confidence interval: 41-56) for ≥CIN3. Three triage strategies with p16/Ki-67 showed a significantly increased specificity with similar sensitivity. P16/Ki-67 triage of all high-risk HPV-positive samples had a sensitivity of 92% (95% confidence interval: 84-97) and a specificity of 61% (95% confidence interval: 54-69) for ≥CIN3. Applying p16/Ki-67 triage to only high-risk HPV-positive women with low-grade Pap cytology showed a similar sensitivity of 92% (95% confidence interval: 84-97), with a specificity for ≥CIN3 of 64% (95% confidence interval: 56-71). For high-risk HPV-positive women with low-grade and normal Pap cytology, triage with p16/Ki-67 showed a sensitivity of 96% (95% confidence interval: 89-99), and a specificity of 58% (95% confidence interval: 50-65). HPV16/18 genotyping combined with Pap cytology showed a sensitivity and specificity for ≥CIN3 similar to Pap cytology with an atypical cells of undetermined significance threshold. Because the quality of Pap cytology worldwide varies, and differences in sensitivity and specificity are limited between the three selected strategies, p16/Ki-67 triage of all high-risk HPV-positive samples would be the most reliable strategy in triage of high-risk HPV-positive women with an increased specificity and similar sensitivity compared with Pap cytology triage.

Financial Incentives and Cervical Cancer Screening Participation in Ontario's Primary Care Practice Models

OBJECTIVES

The primary objective of this paper is to compare cervical cancer screening rates of family physicians in Ontario's two dominant reformed practice models, Family Health Group (FHG) and Family Health Organization (FHO), and traditional fee-for-service (FFS) model. Both reformed models formally enrol patients and offer extensive pay-for-performance incentives; however, they differ by remuneration for core services (FHG is FFS; FHO is capitated). The secondary objective is to estimate the average and marginal costs of screening in each model.

METHODS

Using administrative data on 7,298 family physicians and their 2,083,633 female patients aged 35-69 eligible for cervical cancer screening in 2011, we assessed screening rates after adjusting for patient and physician characteristics. Predicted screening rates, fees and bonus payments were used to estimate the average and marginal costs of cervical cancer screening.

RESULTS

Adjusted screening rates were highest in the FHG (81.9%), followed by the FHO (79.6%), and then the traditional FFS model (74.2%). The cost of a cervical cancer screening was $18.30 in the FFS model. The estimated average cost of screening in the FHGs and FHOs were $29.71 and $35.02, respectively, while the corresponding marginal costs were $33.05 and $39.06.

DISCUSSION

We found significant differences in cervical cancer screening rates across Ontario's primary care practice models. Cervical screening rates were significantly higher in practice models eligible for incentives (FHGs and FHOs) than the traditional FFS model. However, the average and marginal cost of screening were lowest in the traditional FFS model and highest in the FHOs.

Current imaging strategies for the evaluation of uterine cervical cancer

Uterine cervical cancer still remains an important socioeconomic issue because it largely affects women of reproductive age. Prognosis is highly depended on extent of the disease at diagnosis and, therefore, accurate staging is crucial for optimal management. Cervical cancer is clinically staged, according to International Federation of Gynecology and Obstetrics guidelines, but, currently, there is increased use of cross sectional imaging modalities [computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT)] for the study of important prognostic factors like tumor size, parametrial invasion, endocervical extension, pelvic side wall or adjacent/distal organs involvement and lymph node status. Imaging indications also include cervical cancer follow-up, evaluation of tumor response to treatment and selection of suitable candidates for less radical surgeries like radical trachelectomy for fertility preservation. The preferred imaging method for local cervical cancer evaluation is MRI; CT is equally effective for evaluation of extrauterine spread of the disease. PET-CT shows high diagnostic performance for the detection of tumor relapse and metastatic lymph nodes. The aim of this review is to familiarize radiologists with the MRI appearance of cervical carcinoma and to discuss the indications of cross sectional imaging during the course of the disease in patients with cervical carcinoma.

Risk of invasive cervical cancer after atypical glandular cells in cervical screening: nationwide cohort study

OBJECTIVES

To investigate the risks of invasive cervical cancer after detection of atypical glandular cells (AGC) during cervical screening.

DESIGN

Nationwide population based cohort study.

SETTING

Cancer and population registries in Sweden.

PARTICIPANTS

3,054,328 women living in Sweden at any time between 1 January 1980 and 1 July 2011 who had any record of cervical cytological testing at ages 23-59. Of these, 2,899,968 women had normal cytology results at the first screening record. The first recorded abnormal result was atypical glandular cells (AGC) in 14 625, high grade squamous intraepithelial lesion (HSIL) in 65 633, and low grade squamous intraepithelial lesions (LSIL) in 244 168.

MAIN OUTCOME MEASURES

Cumulative incidence of invasive cervical cancer over 15.5 years; proportion of invasive cervical cancer within six months of abnormality (prevalence); crude incidence rates for invasive cervical cancer over 0.5-15.5 years of follow-up; incidence rate ratios compared with women with normal cytology, estimated with Poisson regression adjusted for age and stratified by histopathology of cancer; distribution of clinical assessment within six months after the abnormality.

RESULTS

The prevalence of cervical cancer was 1.4% for women with AGC, which was lower than for women with HSIL (2.5%) but higher than for women with LSIL (0.2%); adenocarcinoma accounted for 73.2% of the prevalent cases associated with AGC. The incidence rate of invasive cervical cancer after AGC was significantly higher than for women with normal results on cytology for up to 15.5 years and higher than HSIL and LSIL for up to 6.5 years. The incidence rate of adenocarcinoma was 61 times higher than for women with normal results on cytology in the first screening round after AGC, and remained nine times higher for up to 15.5 years. Incidence and prevalence of invasive cervical cancer was highest when AGC was found at ages 30-39. Only 54% of women with AGC underwent histology assessment within six months, much less than after HSIL (86%). Among women with histology assessment within six months, the incidence rate of cervical cancer after AGC was significantly higher than that after HSIL for up to 6.5 years.

CONCLUSIONS

AGC found at cervical screening is associated with a high and persistent risk of cervical cancer for up to 15 years, particularly for cervical adenocarcinoma and women with AGC at age 30-39. Compared with the reduction in risk of cancer seen after HSIL management, management of AGC seems to have been suboptimal in preventing cervical cancer. Research to optimise management is needed, and a more aggressive assessment strategy is warranted.

Positive Surgical Margin, HPV Persistence, and Expression of Both TPX2 and PD-L1 Are Associated with Persistence/Recurrence of Cervical Intraepithelial Neoplasia after Cervical Conization

Objective

To determine the clinicopathologic and immunohistochemical predictors of the persistence/recurrence of cervical intraepithelial neoplasia (CIN) after cervical conization.

Methods

Medical records of 502 patients who received cervical conization treatment of CIN between 2005 and 2012 were reviewed. The clinicopathologic parameters were analyzed using Cox hazard regression. Fifty patients with CIN persistence/recurrence were matched to 50 cases without CIN persistence/recurrence. These 100 cervical specimens were assessed for expression of insulin-like growth factor II messenger RNA (mRNA)-binding protein 3 (IMP3), targeting protein for xenopus kinesin-like protein 2 (TPX2), and programmed cell death-1 ligand-1 (PD-L1) using immunohistochemical staining.

Results

Multivariate analysis found that the independent predictors of CIN persistence/recurrence were positive surgical margin (hazard ratio 5.777, 95% confidence interval 2.334–14.301, p < 0.001) and human papilloma virus persistence for 6 months (hazard ratio 20.685, 95% confidence interval 7.350–57.657, p < 0.001). Co-expression of TPX2 and PD-L1 was significantly higher in CIN persistence/recurrence group than the group without CIN persistence/recurrence (p = 0.013). The depth of glandular involvement (GI) was less than 3mm in about 86.8% (59/68) CIN2-3 lesions, However, No statistically significant associations between GI and persistence/recurrence were observed (P = 0.58).

Conclusion

Positive surgical margin, HPV persistence, and expression of both TPX2 and PD-L1 are associated with persistence/recurrence of cervical intraepithelial neoplasia after cervical conization.

Comparative performance of novel self-sampling methods in detecting high-risk human papillomavirus in 30,130 women not attending cervical screening

We determined whether the participation rate for a brush-based cervicovaginal self-sampling device is noninferior to the participation rate for a lavage-based one for testing for hrHPV (high-risk human papillomavirus). Additionally, positivity rates for hrHPV, the detection rates for cervical intraepithelial neoplasia grades 2 and 3 or worse (CIN2+/3+), and user comfort were compared. A total of 35,477 non-responders of the regular cervical screening program aged 33-63 years were invited to participate. Eligible women (n = 30,130) were randomly assigned to receive either a brush-based or a lavage-based device, and a questionnaire for reporting user convenience. Self-sampling responders testing hrHPV-positive were invited for a physician-taken sample for cytology; triage-positive women were referred for colposcopy. A total of 5,218 women participated in the brush-based sampling group (34.6%) and 4809 women in the lavage-based group (31.9%), i.e. an absolute difference of 2.7% (95%CI 1.8-4.2). The hrHPV-positivity rates in the two groups were identical (8.3%, relative risk (RR) 0.99, 95%CI 0.87-1.13). The detection of CIN2+ and CIN3+ in the brush group (2.0% for CIN2+; 1.3% for CIN3+) was similar to that in the lavage group (1.9% for CIN2+; 1.0% for CIN3+) with a cumulative RR of 1.01, 95%CI 0.83-1.24 for CIN2+ and 1.25, 95%CI 0.92-1.70 for CIN3+. The two self-sampling devices performed similarly in user comfort. In conclusion, offering a brush-based device to non-responders is noninferior to offering a lavage-based device in terms of participation. The two self-sampling methods are equally effective in detecting hrHPV, CIN2+/CIN3+ and are both well accepted.

A population-based evaluation of cervical screening in the United States: 2008-2011

BACKGROUND

Cervical screening consumes substantial resources, but little is known about utilization in the United States or compliance with guideline recommendations.

METHODS

To describe population screening coverage, utilization, and outcomes and examine time trends from 2008 to 2011, cervical cytology reports from women residing in New Mexico (981,063 tests from 511,381 women) were evaluated.

RESULTS

From 2008 to 2011 cervical screening utilization decreased at all ages, but especially in younger women, with a two-third reduction at ages 15 to 20 years. Ninety-four percent of women ages 25 to 29 years were screened within 48 months but coverage decreased at older ages to 69% at 45 to 49 years and 55% at 60 to 64 years. Intervals between screening tests were significantly longer in 2011 compared with 2008 [HR = 1.23; 95% confidence intervals (CI), 1.22-1.24], although the commonest rescreening interval was 13 months. In 2011, 91.9% of screening tests for women ages 21 to 65 years were negative, 6.6% showed minor abnormalities, and 1.0% high-grade abnormalities. High-grade abnormality rates were relatively constant over time, but minor abnormalities and atypical cells cannot rule out high-grade (ASC-H) were increasing.

CONCLUSIONS

This population-based evaluation of cervical screening shows high coverage under the age of 40 years, but lower levels in older women. Screening under age 21 years is becoming less common and screening intervals are lengthening, reflecting updates in national screening guidelines.

IMPACT

Assessment of cervical screening intervals and population outcomes is essential for accurately estimating the impact and effectiveness of changing recommendations and vaccination against human papilloma virus infections.

Centralisation of services for gynaecological cancer

BACKGROUND

Gynaecological cancers are the second most common cancers among women. It has been suggested that centralised care improves outcomes but consensus is lacking.

OBJECTIVES

To assess the effectiveness of centralisation of care for patients with gynaecological cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL (The Cochrane Library, Issue 4, 2010), MEDLINE, and EMBASE up to November 2010. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, controlled before-and-after studies, interrupted time series studies, and observational studies that examined centralisation of services for gynaecological cancer, and used multivariable analysis to adjust for baseline case mix.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data, and two assessed risk of bias. Where possible, we synthesised the data on survival in a meta-analysis.

MAIN RESULTS

Five studies met our inclusion criteria; all were retrospective observational studies and therefore at high risk of bias.Meta-analysis of three studies assessing over 9000 women suggested that institutions with gynaecologic oncologists on site may prolong survival in women with ovarian cancer, compared to community or general hospitals: hazard ratio (HR) of death was 0.90 (95% confidence interval (CI) 0.82 to 0.99). Similarly, another meta-analysis of three studies assessing over 50,000 women, found that teaching centres or regional cancer centres may prolong survival in women with any gynaecological cancer compared to community or general hospitals (HR 0.91; 95% CI 0.84 to 0.99). The largest of these studies included all gynaecological malignancies and assessed 48,981 women, so the findings extend beyond ovarian cancer. One study compared community hospitals with semi-specialised gynaecologists versus general hospitals and reported non-significantly better disease-specific survival in women with ovarian cancer (HR 0.89; 95% CI 0.78 to 1.01). The findings of included studies were highly consistent. Adverse event data were not reported in any of the studies.

AUTHORS' CONCLUSIONS

We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.

Implementing the national invasive cervical cancer audit: a local perspective

OBJECTIVE

 To monitor the effectiveness of the cervical screening programme and identify suboptimal management in order to improve patient care.

DESIGN

 Retrospective study.

SETTING

  A university hospital serving a population of 1 million people.

POPULATION

 All women diagnosed with a cervical cancer between 2003 and 2006.

METHODS

  Analysis of data from invasive cervical cancer reviews.

MAIN OUTCOME MEASURE

 Categorisation of cervical cancer cases according to the Invasive Cervical Cancer Audit classification.

RESULTS

  Eighty-seven women were diagnosed with cervical cancer during the 3-year study period. The 'lapsed attender' group accounted for the greatest number of cases (30%), followed by screen detected (26%), interval cancers (13%), never attended (12%), lost to follow-up (10%) and never invited (9%). Women who had never attended for cytology presented with higher stage disease, stage-II or above, compared with the screen-detected cases: 60% were stage II or above, compared with 13.0%, Chi-square P = 0.018. The most frequently identified screening programme problem was patient compliance, which was determined to be the principle contributing factor in 39 cases (45%) and a secondary factor in a further ten cases.

CONCLUSIONS

 The categorisation of cervical cancer cases has the potential of yielding invaluable information for improving programme effectiveness. Patient compliance is the greatest challenge to the screening programme, and the need for regular screening and adherence to follow-up regimens needs to be reinforced in order to maximise the efficacy of the national screening programme.

Empirically evaluating decision-analytic models

OBJECTIVES

Model-based cost-effectiveness analyses support decision-making. To augment model credibility, evaluation via comparison to independent, empirical studies is recommended.

METHODS

We developed a structured reporting format for model evaluation and conducted a structured literature review to characterize current model evaluation recommendations and practices. As an illustration, we applied the reporting format to evaluate a microsimulation of human papillomavirus and cervical cancer. The model's outputs and uncertainty ranges were compared with multiple outcomes from a study of long-term progression from high-grade precancer (cervical intraepithelial neoplasia [CIN]) to cancer. Outcomes included 5 to 30-year cumulative cancer risk among women with and without appropriate CIN treatment. Consistency was measured by model ranges overlapping study confidence intervals.

RESULTS

The structured reporting format included: matching baseline characteristics and follow-up, reporting model and study uncertainty, and stating metrics of consistency for model and study results. Structured searches yielded 2963 articles with 67 meeting inclusion criteria and found variation in how current model evaluations are reported. Evaluation of the cervical cancer microsimulation, reported using the proposed format, showed a modeled cumulative risk of invasive cancer for inadequately treated women of 39.6% (30.9-49.7) at 30 years, compared with the study: 37.5% (28.4-48.3). For appropriately treated women, modeled risks were 1.0% (0.7-1.3) at 30 years, study: 1.5% (0.4-3.3).

CONCLUSIONS

To support external and projective validity, cost-effectiveness models should be iteratively evaluated as new studies become available, with reporting standardized to facilitate assessment. Such evaluations are particularly relevant for models used to conduct comparative effectiveness analyses.

Sentinel Pap smears in 261 invasive cervical cancer patients in Italy

Although cervical cytology screening has dramatically reduced its incidence, cervical cancer still occurs. The clinical history of 261 cervical cancer patients referred to the European Institute of Oncology between 1996 and 2006 was analysed in depth to better understand the difficulties in the diagnosis and prevention of this neoplasia in Italy. Data concerning anagraphical characteristics, tumour type and stage, Pap smear history, colposcopic and histologic data, treatment outcome were reviewed. Patients who had taken Pap smear in the 3-year time span preceding diagnosis were 199 and 55 (27.7%) of these smears were negative. A negative Pap smear was observed in 62.5% of the women with a cancer at stage IV or III. One hundred and seventy-two patients were symptomatic at diagnosis: 43 (25%) had a negative Pap smear in the 3 years preceding diagnosis while 54 (31.4%) had never done a Pap smear or had one taken more than 3 years before. Eighty-nine women were asymptomatic at the time of diagnosis; 13 patients (14.6%) had a negative Pap smear while 8 had no smear taken in the 3 years preceding diagnosis or no smear at all. The present retrospective investigation indicates that the screening system still has some critical points. Although multiple techniques and approaches have been proposed to improve the general performance of the system, prophylactic vaccination may dramatically limit the failures in an easier, and possibly more cost-effective way. We also stress that history taking and clinical examination are important tools to diagnose cervical cancers. However a clinical diagnosis requires experience, which, with the advent of more efficient screening system and prophylactic vaccination, many of the newer practising gynaecologists might lack.

The Prevalence of the Human Papillomavirus in Cervix and Vagina in Low-risk and High-risk Populations

Concordance of HPV between vagina and cervix may be influenced by sample taking and by differences in flow of cervical epithelial cells. To investigate the latter aspect, from 96 women visiting their general practitioner, and 63 sex workers visiting a STI clinic, both vaginal and cervical samples for HPV detection were obtained by the doctor to standardize sample taking. To identify factors that may influence the flow of cervical epithelial cells to the vagina, a questionnaire on intimate hygiene was obtained. The overall HPV prevalence was 22.8%; 14.3% in the general population (14.3% in the cervix, 11.9% in the vagina), compared with 34.4% in sex workers (31.1% in the cervix, 27.9% in the vagina). There was excellent agreement between HPV prevalence in vaginal and cervical samples. The overall agreement was 94.5% (kappa = 0.83, 95% CI: 0.77-0.89); in the general population agreement reached 97.6%, compared with 90.0% in sex workers. Vaginal infection may influence concordance, but for validation of this finding larger studies are necessary. The high concordance found between HPV prevalence in vagina and cervix warrants further study of the applicability of self-sampling to improve coverage rates by attracting women who would otherwise not obtain a pap test.

A case-control study of the protective benefit of cervical screening against invasive cervical cancer in NSW women

OBJECTIVE

To examine the effects of different Pap screening patterns in preventing invasive cervical cancer among women in New South Wales, Australia.

METHODS

A total of 877 women aged 20-69 years diagnosed with invasive cervical cancer during 2000-2003 were matched with 2,614 controls by month and year of birth. Screening behavior patterns in 4 years preceding the time of cancer diagnosis in the cases were classified into none (no Pap test in the 4 years), 'irregular' (1 of the 4 years with Pap test(s)), and 'regular' (2 or more of the 4 years with a Pap test), and compared with those in the matched non-cases over the same period. Conditional logistic regression modeling was used to estimate the relative risk, approximated by the odds ratio, of invasive cervical cancer for regular and irregular cervical screening compared with no screening in the previous 4 years, before and after controlling for potential confounders including the first recorded Pap test result in the preceding 6-year reference period.

RESULTS

Compared with no screening, irregular Pap screening in the 4 years preceding the cancer diagnosis is estimated to reduce the risk of invasive cervical cancer by about 85% (RR = 0.15, 95% CI: 0.120-0.19); regular Pap screening reduces the risk by about 96% (RR = 0.04, 95% CI: 0.03-0.05). After adjusting for the index Pap test result, the relative risks for invasive cervical cancer were 0.19 (95% CI: 0.13-0.27) for irregular screening and 0.07 (95% CI: 0.04-0.10) for regular Pap screening.

CONCLUSIONS

Regular and irregular Pap tests among women aged 20-69 years were highly effective in preventing invasive cancer. At-risk women with no Pap test history should be encouraged to undergo a Pap test every 2 years, but any Pap screening over a 4-year period remains highly protective against future invasive cervical cancer.

Trends in cervical cancer mortality in korea 1993-2002: Corrected mortality using national death certification data and national cancer incidence data

Cervical cancer is a major health problem for Korean women, accounting for 9.8% of new female cancer cases, even though incidence rates have been decreasing. The Korean cervical cancer mortality rate for 1993-2002 based on National Statistical Office data shows an increasing trend, but the actual rates are thought to have decreased by epidemiologists, clinicians and other cancer experts. To explain this gap and solve this problem, we corrected the number of cervical cancer deaths by comparing death certificate cases of unspecified uterine cancer data with the national cancer incidence databases of entire cancer registries in Korea. We used 2 different methods to make a correction. First, we considered "uterus, unspecified" deaths previously registered as "cervix, uterine" cases misclassified and added them to the cervical cancer deaths. Alternatively, we multiplied the total number of registered unspecified uterine cancer deaths by age-specific proportions of registered incident cervical cancer cases among all cancers and added the product to cervical cancer deaths. The overall corrected age-standardized cervical cancer mortality rates per 100,000 women decreased from 5.2 in 1993 to 3.9 in 2002 (estimated annual percentage change (EAPC): -4.05%, 95% CI: -4.88, -3.22). While cervical cancer mortality showed a decreasing tendency in women aged 30-69 years, it increased substantially in women aged > or =70 years (EAPC: 3.62%, 95% CI: 1.92-5.35). Results of this study will provide evidence-based foundation for the evaluation of the existing cervical cancer-screening programs.

Papanicolaou smear history in women with low-grade cytology before cervical cancer diagnosis

BACKGROUND

The purpose of the current study was to examine the screening histories of women diagnosed with invasive cervical cancer (ICC) in 2000 who had previous Papanicolaou (Pap) smears deemed to be unsatisfactory or with low-grade findings that did not lead to biopsy.

METHODS

A total of 252 Pap smears from 47 women taken between 1992 and 2000 were included in the study; 247 smears were reexamined at the laboratory of origin before the study and all 252 were then reexamined independently by 2 experienced cytotechnicians and 2 cytopathologists.

RESULTS

Of the 47 cases of ICC, 35 were squamous cell carcinoma, 10 were adenocarcinoma, and 2 were other types. On reexamination at the laboratory of origin, 24 cases were upgraded and in the study group 27 cases were upgraded to diagnoses requiring biopsy. On reexamination at the laboratory of origin, it was found that the first high-grade squamous intraepithelial lesion (HSIL) could have been diagnosed on average 4.2 years earlier than it was originally (95% confidence interval [95% CI], 3.3-5.1 years). On reexamination by the study group the first diagnosis of HSIL was made in smears dating from 5.4 years before the diagnosis of ICC (95% CI, 4.5-6.2 years).

CONCLUSIONS

The study confirms that unsatisfactory and low-grade Pap smears imply a risk of developing high-grade lesions at a later date and shows that in a screening program a subgroup of smears may be diagnosed as unsatisfactory or low grade despite the presence of high-grade findings that are detectable on reexamination.

[What does HPV vaccination mean for gynecologic cancer screening?]

Human papilloma viruses (HPV) of the high-risk type cause almost all cervical carcinomas and some other anogenital tumors. Development of a carcinoma is uncommon; most infections heal spontaneously. When carcinomas develop, the latent phase is at least 8, more often 15-30 years. A negative HPV test thus excludes the risk of developing cervical carcinoma for many years. The approved vaccine against HPV 6/11/16/18 and the soon-to-be-approved one against HPV 16/18 are extremely safe and effective. Vaccinated individuals are almost 100% protected by the vaccines containing virus-like particles. Current studies suggest that 70-80% of high-grade cervical neoplasias can be avoided, as well as other vaginal, vulvar, and anal neoplasias. The yearly costs for treating precursors of these cancers exceed the cost of vaccinating all girls born in a given year. Thus HPV vaccination is cost effective, even when a modified cancer screening program is retained.

Addressing Taiwan's high incidence of cervical cancer: factors associated with the Nation's low compliance with Papanicolaou screening in Taiwan

BACKGROUND

Despite cervical cancer being the leading female cancer, women in Taiwan have received fewer screening examinations for this disease than populations in Western countries.

METHODS

Randomly selected telephone questionnaire interviews with women aged 20 years and over were conducted to investigate the factors associated with the subject's cancer screening practices.

RESULTS

Among 1021 respondents, 51.6% self-reported no Papanicolaou (Pap) examination received within their lifetime. The multivariate logistic regression analysis revealed that, in addition to marital status, cancer knowledge was the most significant factor associated with screening practice compliance. Compared with women with correct answers for 22-28 cancer knowledge questions, the odds ratios (OR) for non-compliance were 1.4 (95% confidence interval (CI)=1.0-2.0) for women with 17-21 correct answers and 2.3 (95% CI=1.6-3.4) for women with less than 17 correct answers. Women aged 40-49 years had the best cancer knowledge scores. Unmarried women were at an elevated risk for no Pap examination (OR=7.6, 95% CI=5.2-11.3).

CONCLUSIONS

Women in Taiwan should be targeted for intervention to promote cancer knowledge and screening compliance.

Frequent gain of the human telomerase gene TERC at 3q26 in cervical adenocarcinomas

The level of genomic amplification of the human telomerase gene TERC, which maps to chromosome band 3q26, was determined in primary cervical adenocarcinomas. Interphase nuclei prepared from archival material of 12 primary cervical adenocarcinomas, eight of which were human papillomavirus positive, were hybridised with a triple colour probe set specific for centromeres of chromosomes 3 and 7 and the TERC gene. We observed high proportions of nuclei with increased absolute copy numbers for TERC in all tumours (mean 3.3; range 2.3–5.2). Amplification of the human telomerase gene TERC is a consistent aberration in cervical adenocarcinomas. Therefore, application of our probe set may provide an objective genetic test for the assessment of glandular cells in Pap smears and hence for the diagnosis of cervical adenocarcinomas.

Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia

Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is approximately 2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence trends of adenocarcinoma of the cervix in 13 European countries

Rapid increases in cervical adenocarcinoma incidence have been observed in Western countries in recent decades. Postulated explanations include an increasing specificity of subtype-the capability to diagnose the disease, an inability of cytologic screening to reduce adenocarcinoma, and heterogeneity in cofactors related to persistent human papillomavirus infection. This study examines the possible contribution of these factors in relation with trends observed in Europe. Age-period-cohort models were fitted to cervical adenocarcinoma incidence trends in women ages <75 in 13 European countries. Age-adjusted adenocarcinoma incidence rates increased throughout Europe, the rate of increase ranging from around 0.5% per annum in Denmark, Sweden, and Switzerland to >/=3% in Finland, Slovakia, and Slovenia. The increases first affected generations born in the early 1930s through the mid-1940s, with risk invariably higher in women born in the mid-1960s relative to those born 20 years earlier. The magnitude of this risk ratio varied considerably from around 7 in Slovenia to almost unity in France. Declines in period-specific risk were observed in United Kingdom, Denmark, and Sweden, primarily among women ages >30. Whereas increasing specificity of subtype with time may be responsible for some of the increases in several countries, the changing distribution and prevalence of persistent infection with high-risk human papillomavirus types, alongside an inability to detect cervical adenocarcinoma within screening programs, would accord with the temporal profile observed in Europe. The homogeneity of trends in adenocarcinoma and squamous cell carcinoma in birth cohort is consistent with the notion that they share a similar etiology irrespective of the differential capability of screen detection. Screening may have had at least some impact in reducing cervical adenocarcinoma incidence in several countries during the 1990s.

Screening histories of women with CIN 2/3 compared with women diagnosed with invasive cervical cancer: a retrospective analysis of the Norwegian Coordinated Cervical Cancer Screening Program

OBJECTIVE

This study compares the screening history for women with cervical intraepithelial neoplasia (CIN) 2/3 or adenocarcinoma in situ (ACIS) with women with different stages and subtypes of cervical carcinoma.

METHODS

An analysis of the Norwegian Coordinated Cervical Screening Program comparing all cases with a CIN 2/3/ACIS (N=8586) with all ICC (N=777) in the period 2000-2002. All Pap smears since 1992 were used to characterise detection mode and screening history. Multinominal regression models estimated the risk associated with detection mode and adequate Pap smear history.

RESULTS

A wide range of age at diagnosis, from 16 to 92 years of age was observed regardless of the stage of the disease. Fifty five percentage of the women diagnosed with CIN 2/3/ACIS had an adequate screening history. Of women diagnosed with SCC, 45.1% in stage I, and 10.5% in stage IV had an adequate history. The median age of women with CIN 2/3 (34 years) and squamous cervical carcinoma (SCC) stage I (37 years) given an adequate Pap smear history was not significantly different. For women with ACC, the proportion with adequate screening history was roughly 50% for all stages. After adjustment for detection mode and age, the OR for being diagnosed with ICC stage I compared to CIN 2/3 was 1.2 (95% CI: 1.0-1.5), while the OR of being diagnosed with ICC stage II-IV was 3.4 (95% CI: 2.3-4.8).

CONCLUSIONS

Women with CIN 2/3 and ICC stage I were similar with respect to screening histories, i.e. detection mode and age at diagnosis, while women with ICC stage II-IV seldom had an adequate screening history and were diagnosed at a significantly higher age.

A comparison of the human papillomavirus test and Papanicolaou smear as a second screening method for women with minor cytological abnormalities

BACKGROUND

Of the estimated one million Papanicolaou (pap) smears performed annually in Sweden, about 4% show any degree of abnormality. Approximately, 1% of these cases contain moderate or severe atypia (high-grade squamous intraepithelial lesions) and the rest contain low-grade atypia. Recommendations for the management of minor abnormalities vary in various parts of Sweden. Generally, a second Pap smear is obtained 4-6 months after the first one showing low-grade atypia. The aim of this study is to compare the sensitivity of human papilloma virus (HPV)-DNA testing for the detection of cervical intraepithelial neoplasia (CIN) 2-3 with that of a second Pap smear in women, who had low-grade atypia in their first Pap smear.

METHODS

Women with low-grade atypia in the Stockholm area, detected at a population-based cytology screening, were enrolled. A repeat Pap smear, HPV test, and colposcopically directed biopsies were obtained. For the detection of HPV, Hybrid Capture II (HC II) was used.

RESULTS

The HPV-DNA test was positive in 66% of the 177 participating women. The sensitivity of the second Pap smear and HPV-DNA test to detect CIN 2-3 was 61 (95% CI = 45-74) and 82% (95% CI = 67-91), respectively. The positive and negative predictive values of HPV testing were 27 (95% CI = 18-35) and 89% (95% CI = 80-97), respectively.

CONCLUSIONS

In Sweden, a second Pap smear is often obtained for the follow-up of women with low-grade atypia. The results of our study show that compared to the second Pap smear, HPV testing with HC II is a more sensitive method for detecting high-grade lesions.

Cervical cancer mortality is increasing in Spanish women younger than 50

Spanish women seem to have low cervical cancer mortality rates and some studies suggest the trend is stationary; however, this fact remains unclear because a great number of uterine cancer cases are classified as site unspecified. The main goal in this paper is to study mortality trends due to cancer of the cervix in young Spanish women. The percentage of uterus cancer deaths recorded as site unspecified has fallen from 90% in 1965 to 25% in 1995. Mortality by cervical cancer decreases in women aged 25-49 born before 1939-1948 and increases in women born later. This result is shown in each 5-year age group and seems independent from the percentage of unspecified site uterine cancer. In conclusion, Spanish women aged under 50 are suffering an increase in cervix uteri mortality rates; this rise can be related with behavioural changes occurring from 1970-1975 on.

Type distribution, viral load and integration status of high-risk human papillomaviruses in pre-stages of cervical cancer (CIN)

A series of 176 archival cervical intraepithelial neoplasia (CIN) was analysed for the presence, viral load and integration status of ‘high-risk’ types of human papillomavirus (HR-HPV). The samples were assayed using newly developed methods based on real-time PCR. Two methods for the extraction of DNA from the paraffin-embedded biopsies were compared: a protocol based on the MagNA pure system (Roche) and a Qiagen spin column kit (Qiagen). It was possible to amplify 94% (166) of the samples. Of these, 36, 63 and 80% of the CIN I, II and III cases contained HR-HPV. HPV 16 was the most prevalent, and was found in 20, 28 and 46% of the CIN I, II and III cases, respectively. The second most frequent HR-HPV was type 33 group, and in CIN II it was as prevalent as HPV 16. The median number of copies of HR-HPV per cell was not significantly different in the CIN I, II and III cases, but there was a wide range of viral load values over several magnitudes, regardless of the grade of CIN. All samples were found to contain integrated forms of HPV 16, frequently mixed with an episomal form.

Influence of Age on Cervical Cancer Survival in Japan

BACKGROUND

Relative 5-year survival for cervical cancer has been reported to be lower in older women in Japan. A population-based study was carried out to clarify why increased age is associated with decreased survival in spite of a nationwide cervical cancer screening program having been carried out since 1982 in Japan.

METHODS

The Osaka Cancer Registry's data were used to investigate associations between age groups and survival for cervical cancer patients. Survival analysis was restricted to the reported 8966 cases diagnosed in 1975-1996 who lived in Osaka Prefecture (except for Osaka City), or resided in Osaka City in 1993-1996, since active follow-up data on vital status 5 years after the diagnosis were available.

RESULTS

Relative 5-year survival for cervical cancer cases was lower in older age groups (88.6% in <30 years, 78.1% in 30-54 years, 67.7% in 55-64 years and 54.4% in 65+ years), as was the proportion of the detection by screening (6.3, 9.8, 9.2 and 6.0%), the proportion of the localized stage (83.0, 67.3, 51.0 and 42.7%) and the proportion of women who underwent surgery (79.2, 83.2, 65.6 and 35.2%). Among localized cases detected with screening, the survival in those > or =55 years old was >92% and almost comparable with that in 30 to 54 year olds, but significantly lower among those detected without screening.

CONCLUSION

Lower survival among older women was caused mainly by the presence of more advanced disease at diagnosis. Further extension of the nationwide cervical cancer screening program should result in improved diagnosis of earlier stage disease, which might improve differences of cervical cancer survival among these age groups.

Patient-based evaluation of a colposcopy information leaflet

A questionnaire survey of new patients attending the colposcopy clinic of a teaching hospital was carried out. The intention was to evaluate the information leaflet routinely sent to women who have been referred for colposcopy because of abnormal cervical smear results and use the findings to propose changes that will make the leaflet more suitable, effective and patient-friendly. The majority of the respondents received (90%), read (90%) and understood most or all (96%) of the information leaflet. Patients who received the leaflet performed better in the knowledge quiz than those who did not (P < 0.0001). Of the 111 patients who received and read the leaflet 50 (45%) found it reassuring or very reassuring and 58 (52%) thought it made them less anxious. On the contrary 20 (18%) patients found the leaflet worrying or very worrying and 33 (30%) thought it made them more anxious. Overall, 91 (82%) patients found the leaflet helpful or very helpful and 99 (89%) were satisfied with the information provided. The commonest difficulties with the leaflet identified by patients concerned the use of abbreviations and technical terms. We found the leaflet to be a useful method of providing information for patients before colposcopy. Whilst the leaflet appeared to have a major impact on patients' knowledge about abnormal smears and colposcopy, its effect in reducing anxiety was less pronounced.

Should women with genital condyloma acuminata have routine diagnostic colposcopy in addition to cervical smear screening?

We aimed to evaluate the difference in the pick up rate of high grade cervical abnormalities using both primary colposcopy and cervical smear compared with cervical cytology screen only on women with genital warts. We also wished to establish whether this group was at high risk of sexually transmittable infections (STIs) and whether there is a correlation between those with high grade CIN and other STIs. This was a retrospective analysis based in the Department of Genito-Urinary Medicine, Dundee Teaching Hospitals Trust, Dundee, UK. We studied all women (n =117) attending the Department with genital warts between January 1995 and March 1997 who were screened by both cervical cytology and colposcopy High grade cervical abnormalities (CIN II-CIN III) were diagnosed in 10 patients (8.5.%) using cervical screening only and in 41 patients (35%) (CIN II-III) when primary colposcopy and histopathology were undertaken. Of 117 women screened for sexual transmittable infection there were 53 with a positive diagnosis (48%). Of the 53 positive there were 17 women (30%) with high grade CIN. We conclude that women with genital warts are a high risk group, both in terms of having high grade cervical abnormalities and sexually transmittable infection. The result suggests that, when practicable primary colposcopy should be performed as a routine screening tool, on this group of patients over and above cervical cytology screening. All patients with genital warts should be referred to genitourinary medicine for STI screening.

Video colposcopy improves adherence to follow-up compared to regular colposcopy: a randomized trial

OBJECTIVE

To assess and compare rates of adherence to follow-up in women undergoing video or regular colposcopy.

METHOD

Sixty patients with abnormal Pap smears were randomized to undergo video or regular colposcopy. All participants were given the same instructions and a follow-up appointment. If a patient did not keep her appointment and did not reschedule, this was considered a failure. Multivariate logistic regression was used for assessment of predictors of follow-up.

RESULTS

The follow-up rate was significantly higher in the video colposcopy group compared to the regular colposcopy group (80 vs. 50%, p=0.014). After adjusting for results of previous and referral Pap smears, and previous treatment, multivariate analyses indicated that women undergoing video colposcopy were almost five times more likely to return for follow-up than women undergoing regular colposcopy (odds ratio=4.9, 95% confidence interval=[1.24, 19.39]).

CONCLUSION

Colposcopy clinics with patient population similar to ours may consider the use of video colposcope.

Cervical screening in women over the age of 50: results of a population-based multicentre study

OBJECTIVE

It has been suggested that women over 50 with a satisfactory negative smear history are at low risk for dyskaryosis and might be suitable for withdrawal from the cervical screening programme. The objectives of this study are to document the pattern of dyskaryosis in the cervical smears of women over 50 and to relate the risk of dyskaryosis in these women to the prior smear history.

DESIGN

Available computerised smear data were analysed.

SETTING

Five regions in England and Scotland; Aberdeen, Dundee, Birmingham, Gateshead and Nottingham.

POPULATION

All women aged 50 or over who had a satisfactory smear between 1988 and 1996.

METHODS

Smear results were sorted into individual smear records. The first smear after the age of 50 was identified as well as all smears before and after the age of 50.

MAIN OUTCOME MEASUREMENTS

The smear history before and after the age of 50 was determined for all women. The relative risk of dyskaryosis as well as the time to dyskaryosis was calculated for women whose raw data were available.

RESULTS

The study included 170,436 women with at least one satisfactory smear after 50. No results of previous smears were available in 90,546 (54%) of women but 36,512 (21%) of women had a satisfactory negative smear history. Women with prior dyskaryosis or borderline nuclear abnormalities (BNA) had an increased risk of dyskaryosis after the age of 50 compared with women with a negative history (RR 4.39 and 3.08 respectively). It was notable that 1.8% of women with a negative history still demonstrated subsequent dyskaryosis.

CONCLUSIONS

Women with either dyskaryosis or BNA before 50 are not suitable for withdrawal from cervical screening. Well-screened women with a negative smear history at the age 50 still have a residual risk of subsequently developing a new abnormality.

Primary health care and general practice--a comparison between Australia and Malaysia

The Australian and Malaysian systems of general practice were examined and compared. The issues of similarity and difference identified are discussed in this paper. Quality clinical practice and the importance of compulsory vocational training prior to entry into general practice and continuing professional development is one important area. A move towards preventive health care and chronic disease management was observed in both countries. Practice incentive programmes to support such initiatives as improved rates of immunisation and cervical smear testing and the implementation of information technology and information management systems need careful implementation. The Medicare system used in Australia may not be appropriate for general practitioners in Malaysia and, if used, a pharmaceutical benefit scheme would also need to be established. In both countries the corporatisation of medical practice is causing concern for the medical profession. Rural and aboriginal health issues remain important in both countries. Graduate medical student entry is an attractive option but workforce requirements mean that medical education will need individual tailoring for each country. Incorporating nurses into primary health care may provide benefits such as cost savings. The integration model of community centres in Malaysia involving doctors, nurses and allied health professionals, such as physiotherapists, in a single location deserves further examination.

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.

Residual and recurrent lesions after conization for cervical intraepithelial neoplasia grade 3

OBJECTIVES

To evaluate the importance of regular and long-term follow-up of patients who had conization for cervical intraepithelial neoplasia grade 3 (CIN 3); and to assess the risk of residual/recurrent lesions of the cervix uteri.

METHODS

Retrospective analysis of 934 patients with CIN 3 who underwent conization over the period 1 January 1985-31 December 1997. The analysis included 38 (4.1%) patients who had involved resection margins and 896 (95.9%) patients who had free resection margins.

RESULTS

Twenty-three out of 934 (2.5%) patients had another operation (reconization in 17 and hysterectomy in six) whereas one patient had a biopsy. Residual or recurrent lesion after conization was found in 23 patients out of 934 (2.5%). Three patients had invasive cervical cancer (0.3%), 19 had CIN 3 (2.0%) and one patient had CIN 1 (0.1%). One of the 24 patients (4.2%) was diagnosed with no lesion after repeated operation. Eleven patients out of 38 (28.9%) with involved resection margins during the first conization had residual/recurrent disease, compared with eight out of 896 patients (0.9%) who had free resection margins.

CONCLUSION

Another operation is recommended only in cases when, on the basis of cytological, colposcopical and histological findings, the gynecologist suspect the residual/recurrent lesions.