Clinical decision making: from theory to practice. The individual vs society. Is there a conflict?

Eddy argues that many medical interventions that make sense from the point of view of the individual patient and his or her physician might not make sense from the point of view of society -- either because they restrict resources available for other needs, or because they drive up the cost of resources. He illustrates his argument with the case of a hypothetical patient with metastatic breast cancer whose physician offers her an expensive investigative treatment that is 5% effective. The cost of the treatment would buy 10 years of mammogram screening for 150 women. Eddy discusses the nature of the conflict between individuals and society when making judgments regarding the value of different health care activities. He will discuss the resolution of the conflict in a future JAMA article.     

Human papillomavirus screening and cervical cancer prevention

Infection with one of several types of human papillomavirus (HPV) appears to be a necessary first step in the development of invasive cervical cancer. We cannot currently treat HPV infections; thus, the role of HPV testing is to identify women with precancerous lesions that can be removed and, in so doing, prevent progression to invasive carcinoma. Although HPV testing may help to identify women at risk of cervical cancer who might be missed by other screening tests, it is inherently nonspecific at identifying those who would otherwise develop cervical cancer. In order to avoid overtreatment of women with minor lesions with little potential for progression, HPV testing needs to be repeated or combined with Pap smears. Protocols for HPV screening have yet to be properly evaluated. Here we consider several possible applications of HPV testing in the prevention of cervical cancer. The most immediate role is as a secondary test in women with minor cytological abnormalities. Appropriate use of HPV testing as a primary screening tool depends on the setting. In a developed country without an organized screening program, HPV testing might be used in addition to Pap smears in women age 35 and over to increase sensitivity. Within an organized screening program, HPV testing might be used in combination with Pap testing, but with extended screening intervals so as to obtain the maximum advantage to women without unduly increasing costs. Where resources are strictly limited, an attractive option would be to perform visual inspection of the cervix after application of dilute acetic acid using a low threshold for referral, and to test for HPV only on those with abnormal looking lesions.     

Make your office alcohol-exposed pregnancy prevention friendly

This article is third in a series on fetal alcohol spectrum disorders (FASD), and centers on preventing an alcohol exposed pregnancy (AEP). FASDs are 100% preventable if a woman does not drink alcohol during pregnancy. As many pregnancies are unintended, Arkansas providers would best serve childbearing women if they would routinely screen for alcohol use in all childbearing-aged women and encourage women to consider drinking reduction or elimination, or use of an effective method of contraception if they continue to drink alcohol. A systematic process in the clinical setting involving all office personnel enables screening to be a feasible process, otherwise busy clinicians alone often do not have the time to provide these services. A provider other than a physician, such as a trained nurse, can conduct brief interventions after a positive screen while the patient is in the clinic. These brief interventions have been shown to reduce the risk of an AEP. Additionally, there are multiple resources in Arkansas for women who need further treatment for an alcohol use disorder.     

Screening for endometrial cancer

Routine screening for endometrial carcinoma is currently not justified. Postmenopausal women need to be educated about the importance of seeking attention if any vaginal bleeding occurs. All postmenopausal bleeding requires review and appropriate investigation. Women taking tamoxifen have a higher risk of endometrial cancer and should report any bleeding or spotting; however, ultrasound screening is not recommended for asymptomatic women taking tamoxifen. Families with hereditary non-polyposis colon cancer have a higher risk of endometrial cancer and require counselling about this risk. A Pap test is not a screening test for endometrial cancer, but the incidental finding of endometrial cells on a Pap smear in a postmenopausal woman requires investigation.     

The positive experience of screening quality among users of a cervical cancer detection center

BACKGROUND: Our objective was to determine the main factors associated with increased utilization of a cervical cancer screening program (CCSP) in a population with a high mortality rate due to cervical cancer. METHODS: A population-based study was carried out in the Mexican state of Morelos, Mexico. The study population included 3,197 women between the ages of 15 and 49 years who were selected at random using a State Household Sampling Framework in the State of Morelos's 33 municipalities. The sample included 2,094 women with a history of a previous Papanicolaou (Pap) test. RESULTS: A previous experience of good screening quality is strongly associated with greater use of the CCSP (OR = 4.2; 95% confidence interval [CI], 1.6-10.9). The educational level of the head of the family is related to more frequent use of Pap smear services. Women whose husbands have 13 or more years of education (OR = 1.8; 95% CI 1.1-2.9) were more likely to have been screened. Similarly, women who had used two or more family planning methods (OR = 1.6; 95% CI 1.2-2.1) and those who knew why the Pap test was given (OR = 3.0; 95% CI 2.1-4.3) had a better history of Pap screening. CONCLUSIONS: In areas where coverage of cervical cancer screening is low, a CCSP that guarantees the quality of all the different elements of care is essential if obstacles to cervical cancer prevention are to be eliminated. It is of particular importance to take into account and satisfy the perceptions and expectations of the women at risk.     

Breast Alert: An On-line Tool for Predicting the Lifetime Risk of Women Breast Cancer

Breast Cancer is an important disease that affects many women, excluding self-examination and screening by mammogram, nothing helps women or their physicians to know what risk they run of suffering from breast cancer during the course of their lives. There have been many studies detailing the relative risks of breast cancer based on different factors and applications to calculate the breast cancer risk, but none implemented in a way to show lifetime risk. This paper presents an on-line tool (called Breast Alert) to calculate the lifetime breast cancer risk for women using a proposed model. With Breast Alert, physicians can make a quick screening for women when they consult. It is easy to use and intuitive. In a few minutes, physicians can have a lifetime breast cancer risk. This tool does not replace tests like self-examination, breast screening or detection by other options, but allows for the proper precautions to be taken and calls attention to the expected lifetime risk. Nowadays, 300 women (between 20 and 75 years old) from different countries have used the system and most of them (80%) have a higher than normal chance of contracting breast cancer. With these results, it is important to alert of the importance to make an early prevention of breast cancer in different women groups.     

妇科门诊就诊妇女宫颈癌筛查认知行为情况调查

目的探讨妇女对宫颈癌知识的认知和行为情况,并提出相应的干预措施。方法选择2010年1月至2010年6月初次在四川省妇幼保健院就诊的患者采取完全随机法抽取578例进行问卷调查,并根据就诊妇女对宫颈癌筛查知识的认知和行为情况进行分析。结果就诊妇女对宫颈癌筛查相关知识基本了解,知晓率为66.09%。在做过宫颈癌筛查中年龄≤35岁的患者较>35岁的患者数少,其中本市患者较多,家庭月收入≤5000元的患者较>5000元的患者少,未婚已有性生活史者较已婚者少,常住城市者较常住农村者多。结论应加强对35岁以上、高中以下文化、非国家机关和企事业单位、非城市户籍的妇女宫颈癌筛查知识的健康教育,提高知晓率,进一步促进妇女接受宫颈检查及宫颈癌筛查的行为转变。     

南京市65613例体检妇女宫颈癌筛查结果分析

目的探讨宫颈液基薄层细胞学检测（thinprep cytology test,TCT）技术在体检妇女宫颈癌筛查中的作用。方法选取2011年1月~2013年6月期间来我院妇保科体检并进行TCT宫颈细胞学检查的65 613例女性患者,对其中细胞学阳性的患者进行阴道镜检查及宫颈活体组织检查,并以组织病理学结果为最终诊断依据。对这类人群的检查结果做一回顾性研究分析。细胞学诊断标准按照TBS（2001）分类,组织学诊断标准根据WHO2014分类,分别将TCT诊断≥ASCUS为阳性,宫颈活检病理诊断≥CINI为阳性。结果 65 613例TCT细胞学检查中,合格样本61 550例。发现阳性病例（ASC-US及以上）3577例,其中1052例在本院进行了阴道镜检查及活检。TCT诊断的敏感度和特异度分别为79.29%和30.27%。各年龄段的CIN病例分布中51~60岁组的CIN比例高于其他年龄组,且差异有统计学意义（P〈0.05）。结论 TCT是目前较为有效的宫颈癌筛查手段,建议30~60岁妇女每年用该检测技术进行一次宫颈癌的细胞学筛查。     

Breast and cervical cancer screening for older women: recommendations and challenges for the 21st century

The incidence of both breast and cervical cancer increases with age, and older socioeconomically disadvantaged and minority women are most likely to develop or die of these diseases. Early detection has the potential to decrease the disproportionate burden of disease in these vulnerable groups at a reasonable cost to society. Yet despite impressive overall gains in use of mammography and Pap smears, older women, especially older minority women, remain underrepresented in screening programs. Physician recommendation is one of the most powerful predictors of screening across all age, socioeconomic, and ethnic groups. The overwhelming majority of older women, make one or more physician visits each year, each of which represents an opportunity to screen for breast and cervical cancer. Although older women will accept screening if it is offered by their providers, physicians are less likely to offer it to them than to their younger, white patients. Conflicting professional recommendations for screening older women, leaving older women out of clinical trials of screening efficacy, competing causes of mortality with increasing age, and possible negative attitudes held by physicians and patients all contribute to the underscreening of older women. Cancer control challenges for the next century include defining groups of women most likely to benefit from screening (based on age, disease risk, competing mortality, and quality of life), improving regular use of early detection, educating providers, and conducting research on age-mediated differences in breast or cervical cancer biology that could affect screening recommendations.     

Screening mammography in the elderly: a review of the issues

Women age 70 and older have the highest incidence and mortality from breast cancer of any age group. Despite this increased burden of disease, studies show that older women are the least likely to be screened for breast cancer. Barriers to routine mammography in this population include transportation and logistical issues, psychosocial barriers, low literacy levels, and institutional barriers. A variety of interventions, such as community health educators and mobile mammography, have been effective at increasing screening mammography among older women. Although limited, studies have reported that screening mammography reduced breast cancer mortality among women age 65 and older. Research supports continued screening with mammography for elderly women as long as their health is not significantly compromised by comorbid illness, and most organizational guidelines support screening mammography in healthy elderly women. Ultimately, the decision to continue breast cancer screening should be made by the patient and her physician after carefully weighing the risks and benefits of the procedure, which generally become more favorable as women age.     

社区妇女与妇科门诊患者宫颈癌筛查认知情况调查

目的调查社区妇女与妇科门诊患者对宫颈癌筛查的认知情况,并进行对比研究。方法采用方便抽样方法。选择社区妇女312名及笔者所在医院妇科门诊就诊的患者224名。对调查对象进行问卷调查。结果社区妇女宫颈癌筛查知识得分高于妇科门诊患者;在进行宫颈癌筛查的时间间隔上,21．5％的社区妇女可以做到每年1次．51．8％的妇科门诊患者可以做到每年1次;在进行宫颈癌筛查的原因上,69．2％的社区妇女是因为免费体检;66．1％的妇科门诊患者是因为身体不舒服。结论社区妇女对宫颈癌筛查的认知度要高于妇科门诊患者,但妇科门诊患者参加宫颈癌筛查的时间间隔要低于社区妇女,且参加宫颈癌筛查的首要原因与社区妇女不同。     

Awareness and behavior about Pap smear testing in family medicine practice

OBJECTIVE: To describe and estimate the effect of 5 socio-demographic variables and insurance status on awareness of pap smear, and the influence of sociodemographic characteristics, health insurance and knowledge score on having a pap smear test. METHODS: This is a cross-sectional study of 674 female patients, aged 17 years and above between October and December 2006, and attending family medicine clinics at Jordan University Hospital, Amman, Jordan. We collected data on socio-demographic factors, future intention to take the test and barriers to screening. RESULTS: Of 674 patients, 68.1% were aware of the Pap smear as a medical test. Of married women, 40.3% had a screening history. Women who were aware of the test were more likely to be <35 years of age, married, and have higher than secondary education. Women who have had a Pap test were younger and had higher knowledge scores of the Pap smear. The physicians were the main source of information regarding awareness and having the test. Female physicians, particularly gynecologists, were preferred to perform the Pap smear. Fear of the procedure and the results of the test were the major obstacles to having the test. CONCLUSION: There is an imminent need for an awareness campaign; a simple 5-item knowledge test can identify a group of women, who can most benefit from targeted interventions.     

Prostate-specific antigen testing in Ontario: reasons for testing patients without diagnosed prostate cancer

BACKGROUND: The use of the prostate-specific antigen (PSA) test has been increasing rapidly in Canada since its introduction in 1988. The reasons for using the PSA test in patients without known prostate cancer are unclear. This paper reports on the first study in Canada to use physician records to assess the use of PSA testing. METHODS: A questionnaire was mailed to physicians attending 475 patients without diagnosed prostate cancer. The patients were randomly selected from 2 laboratory databases of PSA test records in the greater Toronto area during 1995. The physicians were asked to consult their patient records to avoid recall bias. Information obtained included physician's specialty, patient's age at time of PSA test and reason(s) for the test. RESULTS: There were 264 responses (56%), of which 240 (91%) were usable. Of these 240, 63% (95% confidence interval [Cl] 58%-70%) indicated that the test was conducted to screen for prostate cancer, 40% (95% Cl 34%-47%) said it was to investigate urinary symptoms, and 33% (95% Cl 27%-40%) responded that it was a follow-up to a medical procedure or drug therapy. More than one reason was permitted. Of 151 responses indicating screening as one reason for testing, 64% (95% Cl 56%-72%) stated that it was initiated by the patient, and 73% (95% Cl 65%-80%) stated that it was part of a routine examination. For 19%, both investigation of symptoms and screening asymptomatic patients were given as reasons for testing, and for another 19% both follow-up of a medical procedure and screening were given as reasons. Screening was recorded as a reason for testing far more commonly for patients seen by family physicians and general practitioners than for patients seen by urologists (67% v. 29%, p < 0.001). In contrast, the use of PSA testing to diagnose urinary symptoms was more common for patients seen by urologists than for those seen by family physicians and general practitioners (52% v. 37%, p = 0.044). No significant difference was found between physician groups in the use of PSA testing as a follow-up of a medical procedure (42% for urologists and 31% for family physicians and general practitioners). About 24% of the PSA test records were for patients younger than 50 and older than 70 years. PSA testing initiated by patients was more common in the practices of family physicians and general practitioners than in the practices of urologists (44% v. 13%, p < 0.001). INTERPRETATION: Screening for prostate cancer was the most common reason for PSA testing in our study group; it occurred most commonly in the family and general practice setting and was usually initiated by the patient. Differences in reasons for testing were identified by practice specialty. Although PSA screening for prostate cancer is sometimes recommended for men between 50 and 70 years of age, it is being conducted in men outside this age group.     

农村地区妇女“两癌筛查”项目实施中的问题与对策

宫颈癌与乳腺癌是我国妇女高发的恶性肿瘤，严重影响妇女健康。为降低宫颈癌与乳腺癌的发病率和死亡率，我国从2009年开始积极实施与推广“两癌筛查”项目，并于2016年全面铺开。本文基于对湖南省某市农村地区2016-2017年“两癌筛查”项目实施情况的实地调研，总结项目实施中的问题为：部分农村妇女缺乏“两癌”知识和社会支持，地理交通因素、筛查时间场所安排、对医疗机构的不信任影响妇女参与筛查，部分地区缺乏筛查氛围。提出采取村医参与发动、多重手段反复宣传刺激、当场告知筛查结果和及时回报后续结果、避免推荐非必要的后续服务等对策，以期为该项工作的开展发挥推动作用。     

宫颈液基细胞学检查和杂交捕获二代HPV检测在宫颈癌群体筛查中的价值

目的评价液基细胞学检查(LCT)和杂交捕获二代(HC-Ⅱ)人乳头状瘤病毒(HPV)两种方法不同组合的筛查方案在宫颈癌群体筛查中的价值。方法采用LCT和HC-ⅡHPV两种方法对2004年5月～2009年5月深圳市25～59岁群体妇女共5217例进行同步宫颈癌筛查,对两种检查方法任一项有异常者行阴道镜检查,以病理结果作为最终诊断,评价不同组合的筛查方案在宫颈癌群体筛查中的价值。结果随着宫颈病变级别升高,高危型HPV感染率及LCT阳性率增加(P0.05)。比较六种方案对筛查宫颈上皮内瘤变(CIN)2级及以上病变的价值:HC-ⅡHPV比LCT敏感性高,HPV-LCT平行实验的敏感性和阴性预测值高,以HPV为基础的筛查其特异性和阳性预测值高,HPV-LCT系列实验可减少阴道镜检查的数目,以LCT为基础的筛查可减少筛查实验的数目。结论LCT和HC-ⅡHPV检测均是目前宫颈癌筛查有价值的方法,在宫颈癌群体筛查中,应根据实际情况选择两种方法不同组合的筛查方案。     

高危型人乳头瘤病毒检测在子宫颈病变筛查和处理中的意义及作用

人乳头瘤病毒(HPV)感染是子宫颈癌发生的必要因素,HPV检测可最大程度优化子宫颈筛查和子宫颈异常细胞学的临床处理。对于30岁以上妇女,如HPV检测为阴性且子宫颈细胞学检查正常,可安全地将子宫颈筛查间隔延长至3年。但是,由于HPV病毒感染在年轻妇女中常见且多为一过性感染,因此不建议将HPV检测作为年龄小于30岁妇女的子宫颈筛查内容。对于任何年龄妇女,建议将HPV检测作为未明确诊断的不典型鳞状上皮细胞患者的分流检测方法,同时对于不能除外高度鳞状上皮内病变的不典型鳞状上皮细胞、鳞状上皮内低度病变或不典型腺细胞而未发现中或重度不典型增生的患者,HPV也是随诊方法之一。对于治疗后患者,HPV检测也和阴道镜及子宫颈细胞学一样,可作为随诊方法。HPV检测的正确使用可促进异常子宫颈细胞学的处理。     

2018年延安市农村妇女宫颈癌相关知识认知调查

目的 为延安市农村妇女宫颈癌的综合防治提供科学依据。方法 于2018年1至3月按经济富裕和落后分别随机抽取一个县,其中宜川县随机抽取9个乡镇295名农村妇女,吴起县随机抽取3个乡镇200名农村妇女;自编宫颈癌相关知识认知量表,共33个条目,包括:基本情况、宫颈癌认知、HPV的认知、妇科筛查及认知等,由经过培训的医学专业人员入户一对一进行调查。结果 延安市农村妇女对宫颈癌的认知得分较低,对宫颈癌相关认知的知晓率为19.6%～82.4%,对HPV的知晓率为6.1%～32.5%,13%的女性认为妇科检查不重要,14%以上的女性未做过妇科检查,不同经济状况、不同职业、不同文化程度认知率比较,差异有统计学意义(χ²=7.054、10.797、25.135、39.976、54.849、5.613、15.619、19.997、103.617,均P＜0.05)。结论 延安市农村女性宫颈癌的认知度很低,健康教育和定期筛查是最有效的措施。     

History of medical screening: from concepts to action

The objective of medical screening is to identify disease in its preclinical, and therefore hopefully still curable, phase. This may have been an old quest in medicine but it became historically possible when at least four conditions were met: the availability of simple, valid and acceptable forms of tests, the discovery of effective treatments, the establishment of a theory of screening, and the wide access to health care. Five selected examples that illustrate the history of medical screening are reviewed: screening for psychiatric disorders in the United States army as it is one of the oldest screening programmes; screening for syphilis as it used one of the earliest screening tests; screening for diabetes as one of the first modern forms of mass screening; screening for cervical cancer using the Pap test as one of the greatest successes of screening; and screening for breast cancer by mammography as this offers a good opportunity to discuss the development of modern evaluation of screening programmes. The evaluation of the impact of screening on human health slowly progressed, from obvious changes in the vital statistics such as the decline in incidence of syphilis, to less obvious changes such as the decline in mortality of cancer of the uterus, to finally more subtle changes, such as the impact of mammographic screening on breast cancer mortality. Methods of evaluation had therefore to adapt, evolving from simple surveys to case-control studies and randomised trials. The history of screening is short, but very rich and mostly still to be written.     

子宫颈癌筛查结果异常人群社区管理专家建议

为规范基层医疗机构子宫颈癌防控工作，对子宫颈癌筛查结果异常人群及宫颈病变治疗后人群规范管理与随访，最终降低子宫颈癌发病率，中国医师协会全科医师分会与北京妇产学会社区与基层分会组织有关专家，针对基层医疗机构子宫颈癌防控面临的问题，参照国内国际子宫颈癌筛查及异常管理相关指南，制定《子宫颈癌筛查结果异常人群社区管理专家建议》，主要包括建立健康档案、健康教育、分类管理及上下转诊等内容。该专家建议的发布对提高基层医疗机构子宫颈癌筛查结果异常人群社区管理水平有重要意义。