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PubMed2005

Koilocytosis and squamous (pre)neoplasia as detected in population-based cervical screening: practice and theory.

INTRODUCTION: Koilocytosis (cavitation of the cytoplasm due to active HPV infection) can be detected in the screening process for cervical carcinoma. OBJECTIVE: To report the practice of detection of koilocytosis and (pre)neoplasia in population screening and to exploit the collected data to propose an explanation for the relationship between HPV infection and nuclear precancerous changes. STUDY DESIGN: Centrally collected and stored (SBBW, Leiden, the Netherlands) data from all smears of six regional pathology laboratories (1995-2002), coded according to KOPAC (the national cervical smear coding system; S1: normal thru S9: invasive carcinoma) were accessed. Prevalences per 100,000 smears were calculated for koilocytosis and for squamous abnormalities after stratification for country of origin of screenees. The relative risk (RR) for the ethnic (age) groups was computed by dividing the prevalence of the relevant ethnic (age) group by the prevalence of all women. RESULTS: Surinamese women featured the highest prevalence of koilocytosis and of all squamous abnormalities. Moroccan women the lowest. The RR for koilocytosis was highest at 30 years (1.84) and lowest at 60 (0.26). RR dependence on age of S5-S9 lesions was similar. Compared to nonkoilocytotic smears, koilocytosis was 104 times more frequent in the 1,500 S4 smears, 36x more frequent in the 6,700 S2-S3 smears, and 24x more frequent in the 1,740 S5-S9 smears. In all three categories this difference is statistically significant. CONCLUSION: High prevalences for both koilocytosis and for preneoplasia were detected in Surinamese immigrants, however, it still does not exclude HPV infection as a confounder linked to sexual lifestyle. The presence of koilocytosis in cervical smears may serve to identify patients with an increased risk for cervical cancer and perhaps warrant more intensive surveillance than what is provided through five-yearly screening.

Adult↗

PubMedDate not supplied

Analysis of lifestyle data and cytologic findings in a pilot cervical screening project in rural Vietnam.

OBJECTIVE: To evaluate the possibilities of a cervical cytology screening program and the importance of lifestyle parameters in women living in rural Vietnam. STUDY DESIGN: Screening took place in Quangninh province in the north of Vietnam. From 700 women screened for the first time, smears were prepared and read by a cytotechnologist. The number of children and abortions (some women having had 10 abortions) allowed us to study the relationship of these life-style parameters with disturbed vaginal ecology (defined as the presence of Candida, trichomonads or cocci in the smear). RESULTS: The smears from farmers showed the greatest ecologic disturbances in vaginal flora. Water supply turned out to be important for coccoid overgrowth. Scores for both fungal infection and coccoid overgrowth were related to profession. Candidosis proved to be very prominent in cytologically negative smears: the organisms were found (often in abundance) in 95 of 661 negative smears but were absent from cytologically positive smears. CONCLUSION: Since only two cases of CIN 3 were found and no cases of invasive carcinoma, cervical screening for cancer ought not to be the first priority for rural Vietnam.

Abortion, Habitual↗

PubMed2006

Human papillomavirus in cervical screening and vaccination.

Recent decades have witnessed a reduction in the incidence of cervical cancer in countries where screening programmes have achieved broad coverage. The recognized importance of high-risk HPV (human papillomavirus) infection in the aetiology of cervical cancer may introduce a role for HPV DNA testing in cervical screening programmes. Positive HPV DNA tests indicate women at risk of cervical cancer with greater sensitivity, but reduced specificity, compared with exfoliative cytology. Combining HPV testing with cytology may be useful in the triage of minor cytological abnormalities into those requiring referral to colposcopy (HPV positive) compared with those who can be safely managed by cytological surveillance (HPV negative). With its high sensitivity and high-negative-predictive value, HPV testing may also be useful for predicting treatment failure, since residual disease is very unlikely in the event of a negative HPV test. Ultimately, prevention is better than cure, and the advent of HPV prophylactic vaccines may obviate the need for population-based cervical screening programmes in the future. A multivalent vaccine administered to adolescents prior to the onset of sexual activity and boosted at regular intervals throughout their sexually active life may provide protection against type-specific HPV infection, malignant precursors and invasive cervical disease. Several large randomized placebo-controlled trials have been conducted with promising results. For those generations of women already exposed to high-risk HPV infection, therapeutic vaccines may offer advantages over conventional treatment, although much work still needs to be done.

Female↗

PubMed1989

Cervical screening: what are the communication problems?

Computer-managed call and recall schemes offer the opportunity for effective cervical screening. However, such schemes involve several different agencies, often independent of one another. As a result, problems of communication can arise. This paper discusses potential areas of difficulty and presents some suggestions for improvement.

Adult↗

PubMed1999

A survey of biomedical scientists and consultant pathologists involved in the cervical screening programme.

The past decade has seen a transformation in the National Health Service Cervical Screening Programme (NHSCSP) largely driven by responses to various screening scandals. Independent inquiries into these laboratory failures have identified a number of contributing factors. The aim of this postal survey was to determine how widespread these factors are throughout screening laboratories in England. The results indicate that issues around recruitment and retention of staff, the training of pathologists and low morale appear to be widespread. However, the results do not indicate a widespread breakdown in working relationships between consultants and biomedical scientists, although there is room for improvement in their relationships with hospital management. Finally, there seem to be mixed messages about the commitment of consultants to the screening programme.

Burnout, Professional↗

PubMed2003

Human papilloma virus and cervical screening.

PURPOSE OF REVIEW: There are around 450,000 cases of cervical cancer per year with 300,000 deaths, making it one of the largest causes of death in women worldwide. Dramatic decreases in cervical cancer mortality rates have been seen following the introduction of screening in several industrialised countries. This is despite using a screening test (the cervical smear) that has a fairly poor sensitivity of approximately 55%. Research has centred on finding a better primary or adjunctive test. Issues of cost and acceptability also need to be addressed. It is now widely understood that virtually all cervical cancers are initiated by oncogenic high-risk type human papilloma virus infections, namely human papilloma viruses 16, 18, 30, 31, 33, and 45. RECENT FINDINGS: The confirmed negative predictive value (99%) of a negative human papilloma virus test makes it potentially valuable in the triage of minor smear abnormalities and as post-treatment surveillance. In addition to evidence of its value in triage, there is a growing debate about its use as a primary tool in cervical screening, particularly in settings that do not currently have a structured programme. However, the psychological impact of human papilloma virus testing is less clear. Ultimately, advances in vaccination may hold the key to the eradication of cervical cancer. SUMMARY: This article assesses the recent evidence on the place of human papilloma virus testing in three clinical settings, as a primary screening tool, in triage and as a test of cure. It also reviews the current understanding of the psychological impact of a positive human papilloma virus test.

Female↗

PubMed2006

Improving the NHS cervical screening laboratory performance indicators by making allowance for population age, risk and screening interval.

OBJECTIVE: One of the key performance measures in the monitoring of the NHS cervical screening programme is the targeting of laboratories with very high or low percentages (outside the 10th-90th percentile) of adequate smears that have moderate dyskaryosis or worse. These laboratories are assumed to include those laboratories that may have extremes of sensitivity and specificity. A clear limitation with this methodology is that laboratories do not examine smears from women with the same underlying risk, age distribution or screening interval and adjustment for these factors should considerably improve the method. METHODS: This paper describes a method that allows for these confounding variables and a new age-risk-interval adjusted moderate dyskaryosis or worse rate (ARI-adjusted mod+ rate) can be calculated. The adjusted rate is the rate of moderate or worse dyskaryotic smears that the laboratory would have detected had it been screening women with an English 'average' age-risk-interval. All laboratories can therefore be compared using this method. RESULTS: The methodology is illustrated using data from the NHSCSP South West Region. The particularly low percentage of moderate or worse smears detected by one or two laboratories can be shown to be due to a local screened population with a very low risk because of a high mean age, relatively short screening interval and census variables associated with a low risk, rather than any under-calling by the associated laboratories. CONCLUSIONS: The ARI-adjusted mod+ rate requires to be calculated for all laboratories in England if it is to be used as a primary performance indicator. Alternatively, it can be used to further examine laboratories that are deemed to be outliers using the current methodology.

Adult↗

PubMed1992

Cervical screening: default and compliance.

Health visitors could play a key role in educating at risk women about the benefits of cervical screening. Jane Martin and Peter J Main examine some of the models which outline barriers to screening uptake and consider which will help the health visitor to increase the knowledge and understanding of at risk clients.

Community Health Nursing↗

PubMed1997

A family practice residency cervical screening project: perceived screening barriers.

BACKGROUND AND OBJECTIVES: A community-based family practice residency program initiated a cervical screening project to provide free Pap smears to women who had not had one in 3 years. The research identified reasons why patients had not been screened within the past 3 years. METHODS: A total of 214 consecutive participants in the free Pap smear clinic completed questionnaires. The questionnaire asked about reasons why screening had not occurred over the last 3 years. RESULTS: Altogether, 65.4% of the study group reported cost-related factors as barriers to participation; 37.9% cited either scheduling concerns, fear, or embarrassment; and 36% cited misinformation issues about either screening recommendations, effectiveness of treatment, or disease presentation. CONCLUSIONS: Strategies to increase participation in Pap smear screening clinics may include increasing availability of free or low-cost screening examinations, increasing time efficiency and scheduling flexibility of examinations, and making efforts to mitigate the fear and embarrassment associated with the exam.

Adult↗

PubMed1997

The case for stopping cervical screening at age 50.

OBJECTIVE: To determine the pattern of abnormal cervical cytology in women aged 50 to 60 years and to determine whether the development of cervical neoplasia in this age group is confined to women who have been inadequately screened. DESIGN: Retrospective case analysis study. POPULATION: An 11-year birth cohort of women in Grampian Region born between 2/10/33 and 1/10/44, and those who had significant cytological abnormalities in the 5 year period 1/10/89 to 30/9/94. MAIN OUTCOME MEASURES: Cytological and histological outcome for women with significant cytological abnormalities between 50 to 60 years of age and the interval between three consecutive smears taken up to 50 years of age for those women. RESULTS: Of 23,440 women aged 50 to 60 years ever screened in Grampian Region, 229 (1%) had significant cytological abnormalities. Seventy had CIN 3 and 15 had invasive disease of the cervix. Among approximately 9000 women with adequate smear histories prior to age 50, one case of CIN 3 and one case of invasion were detected. The prevalence of invasive disease in the whole cohort during this five year period was 59/100,000. Among the previously well screened women the prevalence was 11/100,000. CONCLUSION: The incidence of preinvasive disease of the cervix is low over the age of 50 and is seen almost exclusively in inadequately screened women. There would appear to be little benefit in continuing cervical screening over the age of 50 in women who have had regular negative smears. The release of this low risk group from the cervical screening programme could alleviate anxiety and could enable reallocation of resources to target better high risk women who default from regular screening and to reduce screening intervals where necessary to three years.

Age Factors↗

PubMed1999

Cervical screening in the United Kingdom.

It has been more than 10 years since the cervical screening system in the United Kingdom was completely overhauled and a computerised call and recall system was introduced. The current programme is very healthy and dramatic improvements have been made over the past decade. The coverage of the screening programme in England has improved, and incidence and mortality rates have been reduced. Further improvements in compliance, rigorous auditing, and new technologies will likely yield more accurate, efficient, and cost-effective screening programmes in the next decade.

Journal Article↗

PubMed1989

Computerized reminders to encourage cervical screening in family practice.

In a randomized trial three ways of increasing rates of cervical screening were compared for women attending a family medicine center. Working from computerized medical records, 1,587 women aged 18 to 35 years who were overdue for a screening test were included in the study. In a control group, no formal method was used to encourage patients to attend for screening, and 13.7 percent obtained a test within the trial year. In one intervention group the physician was issued a message identifying those women visiting the center for a routine appointment who were due for screening; 16.1 percent were screened. Sending a letter to patients in a second group yielded a 25.9 percent compliance rate. In a third group the practice nurse called patients on the telephone to advise them to obtain the test, and 20.0 percent complied. Reminders issued to the physician provide a low-cost, opportunistic approach to reach women who happen to visit the practice, but this approach should be supplemented by telephoning or sending a letter to those women who do not attend regularly.

Adolescent↗

PubMed2004

A study of knowledge, attitude, and practice of cervical screening among female primary care physicians in the United Arab Emirates.

Cancer is the third leading cause of death In the United Arab Emirates (UAE), which is situated in the Arabian Gulf. A national programme for cervical cancer screening is likely to be implemented in the future. In this study, we assessed the knowledge, attitude, and practice of UAE female primary care physicians of cervical screening through a self-administered questionnaire. Of the 98 physicians who participated in the study only 40% reported ever having performed a Pap smear. In the study, we identified various training needs, and a training programme on cervical screening currently is being developed based on the results of this study.

Adult↗

PubMed2001

The impact of the National Cervical Screening Programme on the presentation of cancer of the cervix in Canterbury.

AIMS: To assess the impact of the introduction of the National Cervical Screening Programme (NCSP) on the presentation of women with cervical cancer to Christchurch Women's Hospital (CWH), a tertiary referral center in Canterbury. METHOD: A retrospective review of the hospital notes of patients diagnosed with invasive cervical cancer from January 1988 to December 1990 and from January 1997 to December 1999. The patient characteristics, mode of presentation and staging during these two three-year study periods were compared. RESULTS: There was a 21% decline in the number of cases of invasive cervical cancer treated at CWH from the Canterbury region from the first to the second study period. There was also a significant clinical down staging at presentation and a significant increase in women presenting with asymptomatic smear detected disease (p=0.004). These changes were less marked in women older than 50 years. There was no change in the relative proportions of different histological types. CONCLUSION: The results reflect a positive impact on the presentation of cervical cancer associated with the introduction of the NCSP in Canterbury. A significant decrease in mortality from cervical cancer in the region can be anticipated. Further emphasis needs to be placed on prevention of cervical cancer in women over 50 years of age.

Adenocarcinoma↗

PubMed2006

Dysbacteriosis and squamous (pre)neoplasia of immigrants and Dutch women as established in population-based cervical screening.

We examined the statistical relationships between dysbacteriosis and (pre)neoplasia related to age and ethnicity from the cervical screening of almost half a million smears. Data from 445,080 smears were coded according to KOPAC (the Dutch national cervical smear coding system) with nine grades. Prevalence per 100,000 smears and relative risks (RR) were calculated for dysbacteriosis and for squamous abnormalities. Patients were stratified by their probable country of origin. Dutch women had an RR of 0.92 for dysbacteriosis. Surinamese women had the highest RR for dysbacteriosis (RR = 2.36) and Moroccan women had the lowest (RR = 1.00). The same trends were seen for the risks of squamous abnormalities. The data for Turkish women follow the patterns of those for Surinamese women. The RR of dysbacteriosis is highest at 50 yr (1.28) and lowest at 35 yr (0.86). When dysbacteriotic and non-dysbacteriotic smears were compared, dysbacteriosis was observed more frequently in smears with squamous abnormalities (4.1% vs. 2.2%). Dysbacteriosis may warrant more intensive cytological surveillance and changes in lifestyle.

Adult↗

PubMed2005

Making sense of information about HPV in cervical screening: a qualitative study.

Introducing human papillomavirus (HPV) testing into cervical cancer screening has the potential to change the way that women understand cervical cancer, the psychological impact of abnormal screening results and the likelihood of future participation in screening. The study used in-depth interviews to examine how women make sense of information about HPV in the context of cervical cancer screening. A total of 74 women were recruited following participation in HPV testing. Women varied widely in their beliefs about the aetiology of cervical cancer and its relationship with sexual activity, as well as in their understanding of the sexually transmitted nature of HPV. While some women who understood that HPV is sexually transmitted were able to integrate this into their existing model of cervical cancer, others were shocked by the link between cervical cancer and sex, of which they had been previously unaware. Women were generally reassured to know that HPV is common, has no symptoms, can lie dormant for many years, can clear up on its own and need not raise concerns about transmission to sexual partners. Women's understanding of HPV varied considerably, even after participation in testing. The way in which information is presented to women will be crucial in minimising the negative psychological impact of testing positive and ensuring that participation in screening remains high.

Adult↗

PubMed2002

Cervical screening for preterm delivery.

The ability of sonographic cervical length screening to detect those at risk of spontaneous preterm delivery has been extensively explored over the past few years. This applies both to high-risk and low-risk groups. Cervical length measurement appears to be superior to biochemical, microbiological or hormonal methods of screening. The screening technique has been standardized, but the cervical length for intervention and the timing and nature of intervention have not been defined. Cervical cerclage appears to be of use to prevent or arrest the progress of cervical dilation in high-risk cases, but the management of the screen-positive low-risk case has yet to be determined. Future management may be stratified according to actual cervical length, and prospective randomized trials of treatment for the short cervix are needed.

Biomarkers↗

PubMed1989

Computer-managed call and recall for cervical screening: a typology of reasons for non-attendance.

Three pilot studies looked at women who had not attended for cervical screening following a computer-generated invitation to a health authority clinic. From these a typology of reasons for non-attendance for computer-managed screening has been developed, specifying inaccessibility, ineligibility, unsuitability, failure of communications, misclassification and refusal because of practical problems, inappropriate beliefs or attitudinal barriers. Underlying the typology are issues connected with the inaccuracy of the database, service organization and provision, and the characteristics of the women themselves.

Appointments and Schedules↗