Factors associated with participation of Korean women in cervical cancer screening examination by age group

Purpose: Cervical cancer is the 6th most common cancer among Korean women, and the prevalence of cervical cancer was 21.9 (per 100,000) in 2008. This study was designed to identify factors associated with Korean women’s participation by age group in cervical cancer screening. Methods: Based on the 2007-2009 Korea Health and Nutrition Examination Survey, we studied 6,964 women who were 30 years or older without a history of cervical cancer and completed a health questionnaire, physical examination, and nutrition examination. Information about their participation in cervical cancer screening examination was collected using a self-administeredquestionnaire. Multiple logistic regression was performed to identify factors associated with their participation in cervical cancer screening over the last 2 years. Results: Approximately 51.9% of women had been screened for cervical cancer over the previous 2 years. Women aged 65 years or older were less likely to undergo the screening than women aged 30-64 years. In the multiple logistic regression analysis, private health insurance, smoking, and body mass index were significantly associated with participation of women aged 30-44 years old in cervical cancer screening examination. Education, health insurance type, private health insurance, and smoking were significantly associated with the participation rate for women aged 45-64 years old. Participation of women aged 65 years or older was associated with private health insurance, body mass index, oral contraceptives, hormone replacement therapy, age at first birth, and number of pregnancies. Conclusion: Indicators of socio-demographic factors, health behavioral factors and reproductive factors seem to have varying impacts on Korean women’s participation in cervical cancer screening according to age group. These results demonstrate the need for more aggressive and age-based interventions and policy programs to improve the cervical cancer screening rate.     

The Korean guideline for cervical cancer screening

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).     

宫颈癌辅助性化疗的探讨

自1989年5月至1996年1月采用改良VBP方案作为宫颈局部肿瘤是巨块型（＞4cm）宫颈癌病例的第一线治疗共48人，142个疗程，无致命性毒性反应，获得了85％以上的有效率，完全缓解达45％，使48例原本只能放疗的患者有41例得以手术根治，而且手术切缘无残瘤。手术标本的病理学评价Ⅲ,Ⅳ级者占鳞癌病例的54％，占临床反应者的63％。淋巴结阳性率为12．1％。辅助化疗组5年生存率79.1％，对照组仅50.8％（P＜0.005）。     

Brachytherapy utilization rate and effect on survival in cervical cancer patients in Korea

ObjectiveExternal beam radiation therapy (EBRT) with concurrent chemotherapy followed by intracavitary brachytherapy is the standard treatment in locally advanced cervical cancer. This study examined the brachytherapy utilization rate and evaluated the effect of brachytherapy on survival in cervical cancer patients in Korea.MethodsIn this study, data from the Korea Central Cancer Registry and Korean National Health Insurance Service and data on mortality from Statistics Korea were linked and used. Patients with other cancers, distant metastasis at diagnosis, or unknown stage or who underwent hysterectomy were excluded. A total of 12,721 cervical cancer patients were analyzed in this study.ResultsThe brachytherapy utilization rate (%) was calculated as the proportion of patients who received brachytherapy among those who received curative EBRT. The brachytherapy utilization rate decreased from 84% in 2005 to 78% in 2013 (p<0.001). Brachytherapy utilization rates varied by region, ranging from 72% to 100% except for in Jeju Island, where the rate was 56%. The brachytherapy utilization rate was lower in patients older than 80 years; patients with localized disease, non-squamous cell carcinoma, or Charlson comorbidity index 3 or more; patients diagnosed after 2010; patients from certain regions; patients receiving medical aid; and patients who underwent gynecologic procedures. Multivariable Cox regression analysis showed that brachytherapy when added to curative EBRT was independently associated with better cancer-specific survival (CSS) and overall survival (OS) than curative EBRT only.ConclusionThe brachytherapy utilization rate decreased from 2005 to 2013 and varied by region in Korea. Brachytherapy use is independently associated with significantly higher CSS and OS in cervical cancer.     

农村不发达地区妇女宫颈癌筛查方法的比较

目的评价多种宫颈癌筛查方式,为农村欠发达地区优选一种较适宜的筛查方法。方法在宫颈癌高发区山西省阳城县对744名年龄为20￣59岁已婚妇女,进行宫颈癌危险因素的流行病学问卷调查、阴道醋酸染色(VIA)、碘染色(VILI)及阴道镜检查并进行13种高危型HPVDNA的检测、收集阴道脱落细胞进行液基细胞学诊断,宫颈有病变者取可疑组织病检。数据用FoxPro6.0录入和整理后,运用SAS软件进行统计学处理和分析。结果CINI以上病例73人,普查人群检出率9.81%(73/744),其中CINⅠ41例,CINⅡ18例,CINⅢ13例,腺癌1例。HPV人群感染率15.99%(119/744)。以病理组织学为金标准(≥CINⅡ为阳性),各检查方法灵敏度和特异度分别为VIA(10.53,82.44),VILI(53.13,82.44),阴道镜检查(56.25,79.35)、液基细胞学(68.75,97.29)和HPV(93.75,87.50)。结论从经济性、适用性综合考虑,VILI在农村不发达地区是一种可行的筛查手段。     

Validation of HPV triage in cytology-based cervical cancer screening for ASC-US cases using Japanese data

ObjectiveIn Japan, cervical cancer screening consists of a cytology examination performed once every 2 years. We verified whether the risk of cervical intraepithelial neoplasia (CIN) 3 disease or higher (CIN3+) was equivalent to that of cytology negative cases (negative for intraepithelial lesion or malignancy [NILM]) for patients with a cytological diagnosis of “atypical squamous cells of undetermined significance (ASC-US)” who tested negative for human papillomavirus (HPV).MethodsData from a total of 22,925 cases who had undergone cervical cancer screening at least twice or who had completed follow-up examinations after cervical screening at a single facility between April 2013 and April 2018 were analyzed. The cumulative incidence of CIN3+ was calculated for each category of initial cytology finding and HPV result (NILM, > ASC-US, ASC-US/HPV (unknown), ASC-US/HPV⁺, and ASC-US/HPV⁻). The statistical analysis was conducted using the Cox proportional hazards model.ResultsThe hazard ratio for the cumulative incidence of CIN3+ in 2 years relative to that for NILM cases was 2.7 (95% confidence interval=1.0–7.8) for > ASC-US cases, 0.5 (0.1–1.7) for ASC-US/HPV (unknown), 0.8 (0.3–2.4) for ASC-US/HPV⁺ cases, and 0.3 (0.1–1.0) for ASC-US/HPV⁻ cases.ConclusionBecause the cumulative incidence of CIN3+ at 2 years for the ASC-US/HPV⁻ cases was sufficiently low, compared with that of the NILM cases, we considered it reasonable and safe to perform HPV triage for ASC-US cases and to allow HPV-negative cases to return for their next screening in 2 years, which is the same follow-up schedule as that for NILM cases.     

适宜农村地区子宫颈癌筛查方法的研究

目的探索适合宫颈癌高发且经济欠发达地区子宫颈癌及其癌前病变的筛查方法,以最终降低子宫颈癌的发病率和死亡率。方法以山西省襄垣县下良乡35￣55岁的妇女作为对象,进行以人群为基础的宫颈癌筛查。对符合条件的妇女进行危险因素、癌症及子宫颈癌认知情况的问卷调查,用醋酸染色后肉眼观察(VIA)和碘染色后肉眼观察(VILI)进行宫颈检查,结果异常者进行阴道镜下活组织检查并得到最终的病理学诊断。将该次筛查对不同级别病变的检出率与历年来的襄垣地区的筛查结果进行比较。结果该次筛查人群参与率为74.8%。患宫颈糜烂和滴虫感染的妇女分别占受检人群的48.3%和14.8%。最终经活检病理确诊的CINⅠ的现患率为0.8%(10例)、CINⅡ0.7%(9例)、CINⅢ1.1%(13例)、子宫颈癌0.2%(3例)。该次单纯肉眼观察对CINⅡ和对≥CINⅢ病变的检出率略低于已往当地普查项目,但差别无统计学意义。结论在资源有限,经济不发达的农村地区,由经过培训的医生进行肉眼观察的宫颈癌筛查是可行的,单纯肉眼观察是一种经济有效的筛查方法,建议进一步在农村地区进行推广。     

Incidence and mortality trend of cervical cancer in 11 cancer registries of China

Objective:In many countries,the cervical cancer prevalence has declined but less information about the changes is available in China.This study aims to understand the epidemiological characteristics and trend of cervical cancer in China.Methods:Cervical cancer data of 11 cancer registries during 1988-2002 in China were analyzed.The age and urban/rural differences and trend of cervical cancer incidence and mortality were described and discussed.Results:During 1988-2002,a total of 6007 incidence cases and 3749 mortality cases of cervical cancer were reported in the 11 cancer registries.The incidence crude rate of cervical cancer was 3.80/100,000 and the world age adjusted rate was 2.78/100,000.In the same period,the mortality crude rate was 2.37/100,000 and the world age adjusted rate was 1.66/100,000.Declined incidence and mortality trends were observed during this period in urban as well as in rural areas.When calculating the rates by age group,we found that the declining trends were only for older women and increasing trends for younger women,especially for women in the rural areas.Conclusion:The incidence and mortality rates declined during the period of 1988-2002 in China for older women.The younger women showed an increasing trend during the same period,especially for women in rural area.     

Increasing trends of cervical adenocarcinoma incidence in Central Italy despite Extensive Screening Programme, 1985-2000

Incidence rates of adenocarcinoma of the uterine cervix have been reported to be increasing in several countries, but not in Italy. The aim of the present study was to analyse trends in cervical cancer incidence by histological type in two districts of Central Italy (Florence and Prato), covered by the Tuscany Cancer Registry (RTT), where cytological screening had been available since the 1970s. Incident cervical cancers during 1985-2000 were 1012. Estimated Annual Percent Change (EAPC) by age-groups and histological type were computed. Incidence increased for adenocarcinoma (EAPC = +5.7%; 95% confidence interval (CI)+2.8; +8.6); whereas, it decreased for squamous cancer (EAPC = -1.9%; 95% CI-3.8; 0) and for other or not specified types (EAPC = -4.4%; 95% CI-10.0; +1.5). Adenocarcinoma increased significantly among younger women (<55 years) but not among older ones, whereas squamous cell cancer decreased among older women only. The burden of cervical cancers might increase in the future if no specific preventive strategies for adenocarcinoma are implemented.     

Epidemiologic and Health Economic Evaluation of Cervical Cancer Screening in Rural China

Background: Cervical cancer is preventable and curable by detected early and managed effectively. To explore the most economical and effective cervical cancer screening strategies would lay a solid foundation for reducing the health and economic burden of cervical cancer. Methods: A Markov model was established for a cohort of 100,000 female to simulate the natural history of cervical cancer. 18 screening strategies were estimated including careHPV, Thin prep cytologic (TCT), Visual inspection with acetic acid/ Lugol’s iodine (VIA / VILI), careHPV in series with VIA / VILI, careHPV in series with TCT, three methods parallel connection every 1, 3, 5 years respectively. Model outcomes included cumulative risk of incidence and death of cervical cancer, quality-adjusted life years (QALYs), cost-effectiveness ratios (CERs), incremental cost-effectiveness ratios (ICERs), cost-utility ratios (CURs) and benefits. Results: According to the results of epidemiological analysis, careHPV similar to the parallel connection every 1 year achieved highest epidemiological effects via reducing the cumulative risk of onset and death by more than 98 %. In health-economic terms, CER among all the screening strategies ranged from -756.34 to 113040.3 Yuan per year and CUR ranged from -169.91 to 11968.27 Yuan per QALY. The benefit ranged from -1629 to 996 Yuan. The incremental cost-effectiveness analysis showed that three methods in parallel every 1 year, TCT every 1 year, VIA/VILI every 1, 3, 5 years and careHPV every 5 years were dominant strategies. Conclusion:Considering the economic and health benefits of all the strategies, our results suggested careHPV every 3 or 5 years and VIA/VILI every 1 or 3 years eventually were more appropriate as screening methods in rural China.     

Epidemiology, prevention and treatment of cervical cancer in the Philippines

Cervical cancer remains to be one of the leading malignancies among Filipino women. High-risk human papillomavirus (HPV) types, such as 16 and 18, are consistently identified in Filipino women with cervical cancer. Factors identified to increase the likelihood of HPV infection and subsequent development of cervical cancer include young age at first intercourse, low socioeconomic status, high parity, smoking, use of oral contraception and risky sexual behaviors. Cancer screening programs presently available in the Philippines include Pap smears, single visit approach utilizing visual inspection with acetic acid followed by cryotherapy, as well as colposcopy. However, the uptake of screening remains low and is further compounded by the lack of basic knowledge women have regarding screening as an opportunity for prevention of cervical cancer. Prophylactic HPV vaccination of both quadrivalent and bivalent vaccines has already been approved in the Philippines and is gaining popularity among the Filipinos. However, there has been no national or government vaccination policy implemented as of yet. The standard of treatment of cervical cancer is radiotherapy concurrent with chemotherapy. Current researches are directed towards improving availability of both preventive and curative measures of cervical cancer management.     

Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India

Objective

To determine the baseline information about the knowledge of cervical cancer and explore attitude and practice of Pap smear screening among staff nurses.

Methods

A pretested structured self administered questionnaire based survey was done on 205 staff nurses working in Rural Institute of Medical Sciences & Research, Saifai, Etawah, containing mostly recognition and some recall type questions about demographics, knowledge about cervical cancer, its risk factors, screening techniques, attitudes towards cervical cancer screening and its practices.

Results

In this study, 74% knew that Pap smear is used for detection of cervical cancer, but only 59% knew that it can detect both cancerous as well as precancerous lesions of the cervix. Only 18% of the respondents knew about human papillomavirus vaccine. A 47% of respondents had never taken a Pap smear; 63% never referred patients for the screening. Most nurses (79%) thought that a speculum examination and Pap smear are procedures to be performed by the doctors. Among all the respondents, only 11% had ever undergone a Pap smear on themselves.

Conclusion

Despite knowledge of the gravity of cervical cancer and prevention by screening, attitudes and practices towards screening were negative.     

Incidence and treatment outcomes of uterine cervical cancer in Korea 1999–2018 from the national cancer registry

ObjectiveTo describe the incidence and survival outcomes of uterine cervical cancer during 1999–2018.MethodsPatients who were diagnosed with cervical cancer during 1999–2018 were identified in the Korea Central Cancer Registry. Age-standardized incidence rates (ASRs) and annual percent changes (APCs) were calculated. Survival rates by histology, year of diagnosis (1999–2008 vs. 2009–2018), stage, and age at diagnosis were analyzed.ResultsThe absolute incidence of cervical cancer decreased over 20 years from 4,488 in 1999 to 3,500 in 2018, with an APC of −3.42% (p<0.0001). While ASR of squamous cell carcinoma (SCCA) more than halved from 13.27 per 100,000 in 1999 to 6.16 in 2018 (APC, −4.04%), adenocarcinoma continued to rise (ASR, 1.30 per 100,000 to 1.92; APC, 1.52%; p<0.0001). Patients with adenocarcinoma were younger than those with SCCA (mean, 49.9±12.7 vs. 52.9 ±14.6 years; p<0.0001). Five-year survival rate of cervical cancer patients overall was 78.0%. Adenocarcinoma had poorer survival than SCCA (5-year survival rate, 76.8% vs. 79.8%; p<0.0001). There was no survival difference between patients who were diagnosed between 1999–2008 and 2009–2018. Earlier-stage disease had better survival (5-year survival rate for localized, regional, and distant disease, 90.0% vs. 69.9% vs. 26.5%; p<0.0001). Younger patients aged <50 years had better survival than those aged ≥50 years (87.1% vs. 69.8%; p<0.0001).ConclusionThe incidence of SCCA of the uterine cervix declined while adenocarcinoma continued to increase slowly but significantly from 1999 to 2018 in Korea. Adenocarcinoma was diagnosed at a younger age, but had poorer survival outcome than SCCA.     

检测尿中巯基筛诊宫颈癌与癌前病变的临床意义

目的：评价检测尿中巯基筛诊宫颈癌前病变、早期宫颈癌、中晚期宫颈癌的临床意义。方法：对1030例宫颈癌前病变、早期宫颈癌、中晚期宫颈癌、非宫颈部位的7种癌以及宫颈正常或宫颈良性炎症妇女,采用子宫颈癌快速自检试剂盒（fast self test—SH for screening cervical cancer,FST—SH）检测其尿中巯基。结果：特异度为94．86％;阳性率、准确度、阳性预测值、阴性预测值、约登指数、阳性似然比,在宫颈癌前病变组为35．71％、87．42％、50．00％、91．11％、0．31、6．95;在早期宫颈癌组为65．87％、87．77％、80．58％、89．78％、0．61、12．82;在中晚期宫颈癌组为80．54％、90．24％、88．17％、91．11％、0．75、15．67：在非宫颈部位的7种癌组为12．41％、60．78％、62．96％、60．59％、0．07、2．41。结论：采用子宫颈癌快速自检试剂盒测定尿中巯基筛诊宫颈癌前病变、早期宫颈癌、中晚期宫颈癌患者,阳性率显著高于非宫颈部位的7种癌（P〈0．01）,且灵敏度随着病情加重而升高（r=0．99,P〈0．05）。根据阳性结果判断为宫颈癌前病变或宫颈癌患者具有较高的准确度和阳性预测值及阳性似然比。根据阴性结果区分为非宫颈癌前病变或宫颈癌患者时具有很高的特异性和阴性预测值。因此,该方法适用于筛诊宫颈癌前病变和宫颈癌,但不适用于筛诊非宫颈部位的7种癌。     

乳腺癌在中国的流行状况和疾病特征

中国女性乳腺癌发病率和死亡率在全球处于比较低的水平,但呈迅速增长的趋势,尤其是农村地区近10年来上升趋势明显。我国女性乳腺癌的发病率和死亡率的年龄和地区分布具有明显特征,总体生存率估计与发展中国家持平,地区和城乡差异明显。目前,尚缺乏以人群为基础的系统资料以描述女性乳腺癌组织病理学、诊断时期别和分子分型等疾病特征的分布。我国乳腺癌的防控策略应更多地侧重于疾病监测、病因学和生存研究,并采取措施提高农村地区乳腺癌预防、筛查和临床诊治服务能力,缩小城乡之间乳腺癌的生存率差距,遏制农村死亡率上升势头。现就中国女性乳腺癌的发病、死亡和生存概况,以及乳腺癌疾病特征的分布状况作一综述。     

妊娠期生理特点与宫颈癌的关系及围妊娠期宫颈癌筛查的意义

目的 探讨妊娠期生理特点与宫颈癌的关系及加强宫颈疾病史妇女围妊娠期宫颈癌筛查的意义.方法 选取2018年1月至2020年1月间陕西省西安医学院第二附属医院妇产科门诊建立档案并接受正规产前检查的22141例孕妇作为研究对象,根据是否处于妊娠期进行分组,妊娠期3328例,非妊娠期18813例.按照自愿原则,受检者接受液基细...     

Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors

BackgroundCervical cancer trends in a given country mainly depend on the existence of effective screening programmes and time changes in disease risk factors, notably exposure to human papillomavirus (HPV). Screening primarily influences variations by period of diagnosis, whereas changes in risk factors chiefly manifest themselves as variations in risk across successive birth cohorts of women.MethodsWe assessed trends in cervical cancer across 38 countries in five continents, age group 30–74 years, using age-standardised incidence rates (ASRs) and age-period-cohort (APC) models. Non-identifiability in APC models was circumvented by making assumptions based on a consistent relationship between age and cervical cancer incidence (i.e. approximately constant rates after age 45 years).FindingsASRs decreased in several countries, except in most of Eastern European populations, Thailand as well as Uganda, although the direction and magnitude of period and birth cohort effects varied substantially. Strong downward trends in cervical cancer risk by period were found in the highest-income countries, whereas no clear changes by period were found in lower-resourced settings. Successive generations of women born after 1940 or 1950 exhibited either an increase in risk of cervical cancer (in most European countries, Japan, China), no substantial changes (North America and Australia) or a decrease (Ecuador and India).InterpretationIn countries where effective screening has been in place for a long time the consequences of underlying increases in cohort-specific risk were largely avoided. In the absence of screening, cohort-led increases or, stable, cervical cancer ASRs were observed. Our study underscores the importance of strengthening screening efforts and augmenting existing cancer control efforts with HPV vaccination, notably in those countries where unfavourable cohort effects are continuing or emerging.FundingBill and Melinda Gates Foundation (BMGF).     

Survival analysis of endometrial cancer patients with cervical stromal involvement

Objective

Stage II endometrial cancer is relatively uncommon. There is no consensus for appropriate adjuvant therapy in endometrial cancer patients with cervical stromal involvement (International Federation of Gynecology and Obstetrics [FIGO] stage II). This study investigates how adjuvant treatments and tumor characteristics influence overall survival (OS) and disease-free survival (DFS) in stage II patients in order to establish better treatment guidelines.

Methods

This multi-institution, Institutional Review Board approved, study is a retrospective review of 40 endometrial cancer patients with cervical stromal involvement treated from 1993 to 2009. Kaplan-Meier estimates were used to evaluate OS and DFS.

Results

OS was 85% at three years and 67% at five years. There were no significant differences in age, histology, depth of invasion, comorbid conditions, surgical staging or recurrence between patients who received radiation therapy (RT) and those who did not. However, patients with FIGO grade 1 cancers were less likely to receive RT (p=0.007). Patients treated with RT had a similar 5 year OS (n=33, 69%) to those treated with surgery only (n=7, 60%, p=0.746). There were no OS differences when evaluating by grade, histology, or depth of invasion between patients who did and did not receive RT. Four patients recurred: three were locoregional failures only, and one failed locally and distant.

Conclusion

Patients receiving RT had higher grade tumors. Despite this, OS was comparable between the RT and the no RT cohorts. Local failure was the predominant pattern of failure. Endometrial cancer patients with cervical stromal involvement likely receive better locoregional control with the addition of adjuvant RT and we continue to advocate for RT in most cases.