Structural barriers to screening for and treatment of cervical cancer in Peru

Through in-depth interviews with 30 key informants from 19 institutions in the health care system in four regions of Peru, this study identifies multiple barriers to obtaining cervical cancer screening, follow-up, and treatment. Some facilities outside Lima do not have the capacity to take Pap smear samples; others cannot do so on a continuing basis. Variation in procedures used by facilities and between regions, differences in women's ability to pay, as well as varying levels of training of laboratory personnel, all affect the quality and timing of service delivery and outcomes. In some settings, perverse incentives to accrue overtime payments increase the lag time between sample collection and reporting back of results. Some patients with abnormal results are lost to follow-up; others find needed treatment to be out of their financial or geographic reach. To increase coverage for cervical cancer screening and follow-up, interventions are needed at all levels, including an institutional overhaul to ensure that referral mechanisms are appropriate and that treatment is accessible and affordable. Training for midwives and gynaecologists is needed in good sample collection and fixing, and quality control of samples. Training of additional cytotechnologists, especially in the provinces, and incentives for processing Pap smears in an appropriate, timely manner is also required.     

Cost of screening and treatment of cervical dyskaryosis in Germany

Human papillomavirus (HPV) infection is the principal cause of cervical cancer. Clinical trials with HPV vaccines have shown high efficacy against HPV-induced precancerous cervical lesions. Before implementing a vaccination programme, up-to-date data on cervical dyskaryosis, incidence and annual treatment costs are needed. We assessed resource use and costs for 12 months following diagnosis for women with abnormal Pap smears in Germany based on a sample of 138 women who had received abnormal results on Pap smears taken during March and April of 2004. Most women had a Pap IIID (57%) vs Pap III (20%) or Pap IV (23%). Women with a Pap IV consulted their gynaecologist more frequently than those with a Pap III or Pap IIID (5.6 visits vs 4.2 and 4.6 visits, respectively). Only 9% of patients underwent colposcopy plus biopsy; this may be due to the lack of histological assessment by coloposcopy and biopsy done currently in Germany. More women in the Pap IV group had a cold knife conisation, compared with those in the Pap IIID group, (84% vs 27%) hysterectomy (22% vs 4%) and laser coagulation (12.5% vs 4%). Median treatment duration was shorter for women with a Pap III than for those with Pap IIID and IV (3 vs 5 months, respectively). Overall, 28.3% of the women were hospitalised (median 5; range 1-33 days). The estimated average annual cost per patient was Euro 1,055, Euro 943 and Euro 3,174 for Pap III, IIID and IV, respectively. The cost of managing precancerous cervical lesions in Germany was shown to be high.     

Guidelines for the follow-up of women treated for high-grade cervical neoplasia

The women treated for CIN2-3 remain at a substantially increased risk of recurrences, which persists longer than 10 years. The women treated for a CIN2-3 are more likely to develop invasive cancer and the risk is two to five times greater than that of the general population. The main objective of the follow-up of patients treated for high-grade CIN is in one hand, to detect and treat the recurrences and on the other hand, to determine a subpopulation presenting a high risk of recurrence which should be followed-up more intensively. At present, frequent follow-up with cytology and colposcopic evaluation of the cervix is the preferred strategy recommended in France by Anaes. Both, the cytology and the colposcopy don't have a very good sensitivity. HPV test is more sensitive compared to cytology or colposcopy in detecting CIN treatment failures. It would be more prudent to use a strategy involving both the cytology and HPV test. Both the sensitivity and the negative predictive value of combined cytology and HPV testing in detecting a residual disease or recurrence are around 100%. Women presenting negative results of both tests, could, then be considered at a low risk of recurrence and their surveillance should be the same as that of the screening of the general population. In case of positivity a more intensive follow-up should be organized.     

"胎儿心脏筛查指南"在产前超声筛查胎儿先天性心脏病中的应用价值

目的 探讨2006年国际妇产科超声协会公布的"胎儿心脏筛查指南"在产前超声筛查胎儿先天性心脏病中的应用价值.方法 2006年9月-2007年7月在南京大学医学院附属鼓楼医院母胎医学中心接受胎儿超声筛查的单胎孕妇5000例.平均年龄28岁(18～48岁),平均孕周27周(妊娠18～40周).以"胎儿心脏筛查指南"为标准对胎儿四腔心和左、右心事流出道及三血管切面进行扫查,对疑有心脏异常者进一步行胎儿超声心动图枪查,对确诊先天性心脏病胎儿建议羊水或脐血穿刺行染色体核型分析,终止妊娠者行胎儿尸体心脏解剖;继续妊娠者,于胎儿出生后2～6个月行超声心动图随访.结果 (1)超声筛查各切面获取率:5000例单胎孕妇中,四腔心切面获取率为97.64%(4882/5000),其中左、右心室流出道及三血管切面的获取率分别为87.69%(4281/4882)、82.51%(4028/4882)和96.29%(4701/4882).5000例孕妇中,孕中期筛查2750例,孕晚期筛查2250例,孕晚期各标准切面的获取率明显低于孕中期(P<0.05).(2)胎儿先天性心脏病发病率:4882例胎儿中最终诊断先大性心脏病73例,发病率为1.50%(73/4882),其中产前超声确诊50例(孕中期24例、孕晚期26例).超声漏诊23例,误诊1例,合并其他器官畸形18例.(3)随访结局:产前诊断为先天性心脏病的胎儿中接受尸体心脏解剖19例,均与产前超声诊断结果一致;继续妊娠者胎儿出生后接受超声心动图检查12例,其中与产前诊断符合11例,另1例产前诊断三尖瓣关闭不全,产后超声检查正常.接受染色体检查23例,染色体核型异常7例.(4)产前超声筛查的敏感性与特异性:四腔心切面确诊先天性心脏病胎儿28例,同时加入左、右心室流出道及三血管切面共诊断先天性心脏病50例,诊断的敏感性为69%(50/73)、特异性为99.98%(4808/4809),假阴性率为0.48%(23/4831),假阳性率为2%(1/51).结论 国际妇产科超声协会2006年公布的"胎儿心脏筛查指南"临床实用、易于遵循、便于操作.就最佳超声切面获得来说,孕中期(18～27周)是最佳筛查时间.胎儿四腔心和左、右心窒流出道及三血管切面同时筛查,可产前诊断69%的先天性心脏病胎儿.     

Use of visual screening methods for cervical cancer screening

This article has considered recent advances in visual screening methods. Devices that use electro-optical sensors offer great potential in various clinical roles, but considerable additional work is required to develop these devices and it is unlikely that they will come into widespread clinical use in the next 5 years. In contrast numerous studies, demonstrate that simple visual screening methods, such as DVI, have a sensitivity for the detection of women with biopsy-confirmed high-grade SIL (CIN 2,3) and cancer that is equivalent to that of conventional cervical cytology. The primary disadvantage of the simple visual screening methods is poor specificity. These methods classify up to 30% of all women screened as being test positive and as a result new strategies toward managing DVI positive women must be developed before simple visual screening methods can be adopted for routine screening. Enhanced visual methods that use cervicography and speculoscopy may be more specific and improve detection of biopsy-confirmed SIL, but the added time and expense to perform either of these methodologies must be considered and justified. Currently numerous studies are evaluating the best strategies for incorporating visual screening methods into cervical cancer screening programs. In the near future we should be able to determine whether these approaches should be incorporated into routine clinical care.     

Optimal cervical cytology mass screening interval for cervical cancer

Objective

To identify the optimal interval for repeat cervical cytology testing for screening of cervical cancer and dysplasia in healthy female adults.

Design and methods

A retrospective cohort study was conducted on 3,804 apparently healthy females without known cervical cancer at baseline from 2005 to 2010. Participants underwent annual health checkups, including cervical cytology testing. This data did not contain human papillomavirus status. Participants with cytological abnormality underwent further examination, including biopsy, to check for cervical cancer. The generalized estimating equation (GEE) was performed to analyze the longitudinal data.

Results

In the groups <40, 40–49, 50–59 and ≥60 years old, the 5-year cumulative incidences (95 % CI) of cytological abnormality were 11.2 % (8.8–13.9 %), 7.6 % (6.2–9.3 %), 4.4 % (3.3–5.7 %) and 2.8 % (1.8–4.2 %), respectively, and the cumulative incidences of cervical cancer were 0.9 % (0.3–2.0 %), 0.1 % (0.0–0.4 %), 0.1 % (0.0–0.5 %) and 0 %, respectively. The odds ratios of the incidence for cervical cancer and cervical dysplasia per year, with GEE models, were 1.5 (95 % CI:1.1–2.0), 1.2 (95 % CI:0.8–1.9), 2.2 (95 % CI:0.5–10.3) and 0 for cervical cancer, and 1.3 (95 % CI:1.2–1.5), 1.3 (95 % CI:1.2–1.5), 1.3 (95 % CI:1.1–1.5) and 1.4 (95 % CI:0.9–2.0) for cervical dysplasia, respectively.

Conclusions

For patients under 40 years old, the screening for cervical cancer every 2 years should be considered, while for patients of 40–59 years old screening every 2 or 3 years should be considered. Females over 60 years old may only need repeat screening every 5 years.     

宫颈癌筛查系统及液基细胞学检测在宫颈病变筛查中的对比研究

目的:探讨宫颈癌筛查系统(TruScreen)与液基细胞学检测(liquid-based cytologytest,LCT)在宫颈病变诊断中的临床意义。方法:对487例患者行TruScreen、LCT检查,以阴道镜下病理学检查为金标准。比较两种方法的敏感度、特异度及假阴性率。结果:TruScreen、LCT阳性结果分别为229例和42例,病理学检查阳性结果为30例。Tru-Screen、LCT及TruScreen联合LCT检测的敏感度分别为73.3%、46.7%和90%,特异度分别为54.7%、93.9%和50.5%,假阴性率分别为26.7%、53.3%和10%。TruScreen及Tr-uScreen联合LCT检查敏感度高于LCT,差异有统计学意义(P<0.05),TruScreen与Tru-Screen联合LCT检查的敏感度无统计学差异(P>0.05)。结论:本研究中,TruScreen的效果评价高于LCT。在我国,TruScreen作为一种新的宫颈病变筛查技术可能会达到较好的筛查效果。     

New technologies for cervical cancer screening

New technologies for cervical cancer screening seek to provide an accurate, efficient and cost-effective way of identifying women at risk for cervical cancer. Current screening uses human papilloma virus DNA testing combined with cytology, and requires multiple visits at a great cost to the patient and society. New methods for screening include HPV diagnostics (detection of either the presence of human papilloma virus or integration of the virus into the host cell), proliferation, and detection of epigenetic changes, either in the host or virus. These methods show promise in changing the way that current cervical cancer screening is undertaken in low-and high-resource settings.     

Primary HPV screening for cervical cancer

Cytology-based cervical screening had unequivocal success in reducing the incidence and mortality of cervical cancer in the last century. The recognition of the role of human papillomavirus (HPV) as a necessary cause of cervical cancer led to the development of HPV testing. Gradually, there has been a shift from reflex HPV testing for mild cytological abnormalities, to co-testing with cytology and HPV, and lately to primary HPV screening, based on evidence from well-designed large randomized controlled trials and meta-analyses. Advantages of primary HPV screening include higher sensitivity to detect pre-neoplastic lesions, better re-assurance with a negative test, and safe prolongation of screening intervals. However, clinicians and policy makers must ensure the availability of clinically validated HPV assays and triage protocols of screen positive cases prior to implementation of primary HPV screening. This is likely to reduce potential harm from over-treatment as well as extra burden on the health care system.     

Cytological screening for cervical cancer prevention

Historically, the incidence and mortality of cervical cancer has declined in countries that have instituted and sustained mass-organised cytology-based screening programmes. These programmes, however, required frequent repeats of the screening tests. They also require a functioning healthcare infrastructure, with laboratories for smear processing and interpretation, mechanisms for quality control, referral for colposcopy, treatment of precursors, and follow-up to detect failures of treatment. Although this approach has been successful in preventing cervical cancer where implemented correctly, it has proved inordinately complex and expensive for developing countries. Consequently, no successful screening programmes have been established in poor countries, and cervical cancer remains the most common cancer among women in developing countries, despite the existence of cytology and the knowledge of cervical cancer prevention. New technologies, specifically the development of liquid-based cytology, have improved the performance of cytology as a screening test, but do not obviate the infrastructural challenges posed to health systems by cytology-based screening programmes. In this chapter, the history of cytological screening and the challenges posed by secondary prevention strategies are reviewed.     

The fallacy of the screening interval for cervical smears

One hundred seventy-four women with invasive cervical carcinoma were interviewed about their cervical smear histories to assess the accuracy of self-reporting and to relate the smear history with patient and tumor characteristics. Patients reported significantly more frequent, more recent, and more normal smears than were documented in medical records. The interval between onset of cancer symptoms and previous smear correlated directly with advanced stage. Sixteen women with normal smears within 36 months had significantly more advanced cancers than did 25 women with recent abnormal smears. Women with recent normal and abnormal smears had similar sociodemographic and behavioral characteristics. Because of inaccuracies in patients' self-reported smear histories and cancers developing in women with recent normal smears, we conclude that a specific screening interval should not be relied upon.     

宫颈癌医院机会筛查与社区筛查相关因素分析

目的分析宫颈癌医院机会筛查和社区筛查的相关因素。方法对2008年1月至2008年12月在北京市垂杨柳医院妇科门诊行宫颈癌机会筛查和社区筛查妇女的相关因素进行分析,其中门诊机会筛查7223例（机会筛查组）,社区筛查11539例（社区筛查组）。结果社区筛查组年龄[（45.75±9.29）岁]大于门诊机会筛查组[（33.55±10.49）岁],其中社区筛查组年龄〉50岁者占39.8%,初中及以下文化程度者占96.2%,两组筛查妇女年龄比较,差异有统计学意义（P〈0.001）。两组宫颈鳞状上皮内低度病变所占比例（机会筛查组1.2%;社区筛查组0.4%）比较,差异有统计学意义（P〈0.001）;机会筛查组鳞状上皮内高度病变及宫颈癌发生率高于社区筛查组,但差异无统计学意义（P〉0.05）。机会筛查组不同级别的宫颈上皮内瘤变（CIN）和宫颈癌的检出率均高于社区筛查组,差异有统计学意义（P〈0.05）。结论社区筛查人群年龄较大,文化程度低,应重视这一群体防癌知识宣教,提高筛查率。宫颈癌医院机会筛查与社区筛查同样重要。     

宫颈癌的筛查

对无症状健康妇女开展以细胞学检查为主要手段的宫颈癌筛查，可使宫颈癌的诊断提前到临床前癌，故近60年来西方发达国家官颈癌的发病率呈现了明显下降趋势。我国由于诸多原因，宫颈癌筛查的开展与发达国家相比尚不理想，宫颈癌仍是威胁妇女健康的主要疾病。因此，根据各地区宫颈癌发病和经济状况，对合适人群采用合适手段进行宫颈癌筛查具有重要的临床和社会意义。