Uterine cervix cancer. A major public health problem in Jamaica.
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Biomedical subjects
Publications and source records attributed to V Persaud.
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The availability of age-standardized cancer incidences for different parts of the world has enabled a thorough and meaningful analysis of the geographical distribution of cancer of the uterine cervix. The high morbidity and mortality from cervical cancer reported for most European countries and North America at the beginning of this century has, in recent years, been superseded by those for Asian, African, Latin American and Caribbean countries with the provision of additional data. Striking differences in cervical cancer incidences have been observed among various ethnic groups in Africa which seem to reflect variations in the intensity of certain environmental influences. Cervix cancer is uncommon in the white population of North America and Europe with the exception of West Germany, Denmark, Sweden and Yugoslavia. In the United States, the highest incidence occurs in Puerto Rican women of New York City and the Latin population of the South. The very low incidence in Jewish women is virtually the same in New York City as in Israel. This world-wide survey has shown that poor sexual hygiene rather than lack of male circumcision per se is a more important aetiological factor in cervical cancer.
Fifty-two cases of choriocarcinoma were recorded in the Jamaica Cancer Registry for the parishes of Kingston and St. Andrew, giving an incidence of 1:7,384 live births. This is intermediate between figures reported for Western metropolitan populations and for Far Eastern countries. Clinicopathological studies on 26 cases treated at the University Hospital in Jamaica revealed that 65% followed either normal pregnancy or abortion. Choriocarcinoma following a normal pregnancy or occurring without a previous history of pregnancy carried a poorer prognosis than those with a preceding hydatidiform mole. Many patients had primary neurological manifestations. The overall prognosis was poor due to late presentation with disseminated metastases. Of the 26 patients, 15 died of the disease within two years and only six appeared for a six-year follow-up.
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A morphologic investigation on 100 cervices removed at autopsy from negro Jamaican women at different ages showed that columnar epithelium was frequently located on the portio vaginalis at all ages. The absence of this phenomenon in some fetal cervices supports the hypothesis of embryologic displacement rather than stimulation by maternal estrogens. Squamous metaplasia was common at all ages, even in the fetus; it showed little relationship to chronic inflammation, but the high frequency in post-pubertal cases (80%) could have some relationship to the high incidence of cervical cancer in Jamaica. Chronic inflammation was not observed in the fetal cervix but occurred in most infants in whom it was attributed to congenital "erosion". However, the cervices of children revealed a marked discrepancy between the presence of "erosion" and the degree and frequency of chronic inflammation (83%). This change is unexplained and requires further study.
Twenty-five patients with the diagnosis of carcinoma-in-situ (CIS) of the cervix were treated with colposcopy guided epithelial conization. During the follow-up study of 4-7 years' duration, there was no recurrence of CIS in 20 of the 25 patients. Between 6 and 12 months after conization, 3 patients showed recurrence of CIS. Two of these patients were treated with further epithelial conization with no evidence of further recurrence 4 years after the second treatment. The third patient refused to accept further epithelial conization and modified radical hysterectomy was done without any evidence of residual tumour in the hysterectomy specimen. One patient showed stromal invasion in both colposcopically guided biopsy and bone biopsy. Modified radical hysterectomy specimen showed remnants of stromal invasion. One patient with Class IV smear failed to show any atypical transformation zone and cervicitis was proven on colposcopy guided biopsy following treatment with Flagyl. For two of the 25 patients, cytology was Class II and therefore failed to diagnose the pre-malignant condition; but colposcopy showed a grade 3 atypical transformation zone and the presence of CIS was confirmed histologically. Simultaneous use of cytology, colposcopy and colposcopically guided biopsy confirmed the diagnosis of CIS in all cases. The authors recommend colposcopically guided epithelial conization in younger patients, provided the malignant lesion is strictly intra-epithelial, and limited to the ectocervix. Routine follow-up with the aid of cyto-colposcopy remains the key factor in this schedule of therapy.
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