Implementation of Comprehensive Screening for Cervical Cancer in Canada: Impediments and Facilitators

Cervical cancer screening has been available in Canada for over 50 years, and numerous task forces and workshops have recommended that organized screening programmes should be implemented. Despite this, the majority of screening in Canada take place in an opportunistic fashion and cervical cancer still occurs in 1996. This paper describes the history of screening in Canada and the current activity at provincial and national levels. It also identifies the impediments to the development of comprehensive screening programmes as recommended over the years. Factors which can act as facilitators to the implementation of such programmes and the role of physicians in achieving them are also identified. Currently, at a national level, a Cervical Cancer Prevention Network has been formed. This is an informal association of provincial and federal health department representatives with the College of Family Physicians of Canada, die Canadian Society of Cytology, the Society of Obstetricians and Gynaecologists of Canada, the Gynaecologic Oncologists of Canada, and the Society of Canadian Colposcopists. The purpose is to facilitate the development of quality organized screening programmes in all provinces and territories.     

2005年中国12家医院宫颈癌机会性筛查资料分析

目的:探讨中国不同地区进行宫颈癌机会性筛查的价值.方法:收集分析2005年全国12家医院门诊进行宫颈癌机会性筛查(oppommistic screening,OS)的资料,筛查方法包括液基细胞学、巴氏细胞学、高危型HPV检测,以及中国癌症基金会推荐的Ⅰ方案(液基细胞学检查加高危型HPV DNA检测)、Ⅱ方案(巴氏涂片加高危型HPV DNA检测)、Ⅲ方案(醋酸白肉眼检查法);并经阴道镜检查,病理确诊宫颈病变及宫颈癌.结果:共收治门诊患者1242952例次,其中接受OS202231例次,占门诊例次16.27%.筛查方法依次为液基细胞学84082例(41.58%),巴氏细胞学79426例(39.27%),Ⅰ方案23658例(11.70%),Ⅱ方案6504例(3.22%),检测HPV筛查者5976例(2.96%);Ⅲ方案2585例(1.28%).最普遍采用的筛查方法是细胞学检查(液基及巴氏方法)占95.76%.检出宫颈癌前病变(CIN Ⅰ+CIN Ⅱ+CIN Ⅲ)共5146例(2.54%),宫颈癌1134例(0.56%).结论:医院内就诊人群宫颈病变检出率高,应高度重视其机会性筛查,及时进行规范性治疗.     

Cervical Cancer Screening in the United Kingdom, 1986 to 1996: A Decade of Change

Screening far cervical cancer started in the United Kingdom in the mid’-1960s, mainly as a clinically-led service offered by gynaecologists on an opportunistic basis to women who attended for reproductive care. By the early 1980s, the mortality rate was eight per 100,000 women, which compared unfavourably with other developed countries. In 1986, the National Audit Office to the Parliamentary Committee of Public Accounts urged the introduction of comprehensive screening using computerized call and recall systems. In 1988, the National Coordinating Network of the NHS Cervical Screening Programme (NHSCSP) was set up. The history and complexity of organizing the NHSC-SP and the accomplishments to date are described in this paper.     

宫颈癌住院患者10年临床特点变化及筛查作用探讨

目的:探讨10年来宫颈癌住院患者的临床特点变化及"两癌筛查"开展5年以来宫颈癌筛查的作用。方法:回顾性分析2005年1月至2014年12月在北京大学第一医院妇产科确诊为宫颈癌的718例住院患者的临床资料,按户籍所在地分为北京市和外省市两组;按"两癌筛查"前后分为2005~2009年组和2010~2014年组,分别比较基础资料、诊断途径及肿瘤分期等临床特点。结果:110年来我院收治的宫颈癌患者数量呈上升趋势。北京市患者的平均发病年龄、结婚年龄、初产年龄均高于外省市(P0.05),而中位孕次和产次均低于外省市(P0.05)。北京市患者中体检发现比例和ⅠA期患者比例均高于外省市(P0.05)。2"两癌筛查"前后各项指标的比较中,仅筛查后的发病年龄高于筛查前(P0.05),其他项目的比较差异均无统计学意义(P0.05)。3北京市患者中以西城区患者最多。外省市患者前3位是河北省、内蒙古自治区和山西省。结论:北京市宫颈癌患者在早婚、早育、多产等高危因素方面优于外省市患者,外省市宫颈癌筛查宣教和实施筛查的力度需进一步加大,扩大体检发现率和ⅠA期发现率。"两癌筛查"的作用尚未体现,还需要长期坚持、广泛开展。     

The Role of the Gynaecologist in the UK Cervical Screening Programme

Opportunistic cervical cancer screening began in the United Kingdom in a fragmented manner in the 1960s. Recognizing the failure of this approach to reduce the morbidity and mortality from this preventable cancer, a more structured approach, the National Health Service Cervical Screening Programme, has been in place since 1988. Guidelines for practice and programme management have been developed with the collaboration of the Royal Colleges and those involved in programme delivery. The implementation of quality assurance guidelines for the programme and standards for quality colposcopy services has allowed measurement of me effect of the programme; audits have shewn acceptance of the guidelines. Changes in mortality that had not occurred prior to the implementation of this coordinated programme are beginning to show that the Health of the Nation Target of reducing the incidence of invasive cancer of the cervix by 20 percent by the year 2000 compared to the 1986 rate can be achieved.     

p16/Ki-67双染在宫颈癌及癌前病变初筛中的应用价值研究

目的:评价采用p16/Ki-67双染检测技术作为宫颈癌及癌前病变初筛方法的效果及应用价值。方法:对重庆市万州区982例年龄35~64岁有性生活的妇女进行宫颈癌筛查。每位妇女均接受了人乳头瘤病毒DNA(HPV DNA)检测、Thin Prep液基细胞学检查、p16/Ki-67双染检测,对结果异常者进行阴道镜检查,阴道镜下在可见病变处直接取活检,无可见病变时,行宫颈管搔刮术(ECC)。比较3种方法分别作为初筛手段识别宫颈癌前病变(高级别鳞状上皮内病变)及浸润癌的灵敏度、特异度、阳性预测值和阴性预测值等指标,以受试者工作特征(ROC)曲线下面积(AUC)综合分析3种方法作为宫颈癌初筛手段的应用价值。结果:最终966例妇女进入研究,共检出高级别鳞状上皮内病变及浸润癌患者42例。HPV DNA检测、液基细胞学检查和p16/Ki-67检测对宫颈癌及癌前病变患者的灵敏度分别为97.6%、88.1%、92.9%;特异度分别为84.1%、78.8%、82.8%;阳性预测值分别为21.8%、15.9%、19.7%;阴性预测值分别为99.9%、99.3%、99.6%。p16/Ki-67检测的AUC分别与HPV DNA检测、液基细胞学检查相比,差异均无统计学意义(P0.05)。结论:p16/Ki-67双染检测初筛宫颈癌及癌前病变的效果与HPV DNA检测及液基细胞学检查相似,因其具有简便、客观、高效、易于重复的特点,p16/Ki-67双染检测为宫颈癌及癌前病变的有效初筛提供了一种新选择。     

Complementary Procedures in Cervical Cancer Screening in Low Resource Settings

Objective

To evaluate the efficacy of pap smear, HPV DNA testing and colposcopy and to determine the approach for cervical cancer screening in low resource settings.

Methods

Eight hundred non pregnant married women above 30 years of age were studied and subjected to pap smear examination. Hysterectomised women were excluded from the study. Selected patients were followed by HPV DNA testing by Hybrid Capture II method, colposcopy and biopsy. Sensitivity, specificity, Positive predictive value (PPV), Negative predictive value (NPV), diagnostic accuracy and kappa value (k) were calculated for each screening test.

Result

Out of eight hundred women with mean age 36.5 ± 5.94 years undergoing pap smear, ASCUS was found in 66(8.25%), ASC-H in 2(0.25%), LSIL in 48(6%), HSIL in 8(1%), inflammatory in 540(67.5%). Out of 260 women who underwent HPV DNA testing, 120 (46.15%) had abnormal cytology and/or positive HPV DNA test (Group I, n = 120) and 140(53.8%) had dual negative results (Group II, n = 140) HPV DNA test was found positive in 64 women (53.3%) in Group I. Sensitivity and specificity of pap smear was 69.2 and 63.72% while for HPV DNA testing was 92.3 and 84% respectively. PPV and NPV of pap smear, HPV DNA testing and colposcopy was 18, 40, 76.4% and 94.7, 98.9, 100% respectively. Diagnostic accuracy of pap smear (k = 0.14), HPV DNA test (k = 0.70) and colposcopy (k = 0.81) was 64.29, 84.9, and 96.8% respectively. Combining pap smear &; HPV DNA testing (k = 0.25) increased the sensitivity and NPV to 100%.

Conclusion

Sensitivity and diagnostic accuracy of HPV DNA test is more than that of pap smear and the test is not influenced by inflammatory conditions of vagina. In low resource settings, women with ASCUS and LSIL on cervical cytology should be subjected to HPV DNA test and only if found positive should be referred for colposcopy thereby reducing colposcopy referrals. Women with HSIL should be directly subjected to colposcopy guided biopsy. Using this approach, most of the preinvasive cervical lesion will be detected but few cases will still be missed among inflammatory smears, if HPV DNA testing is not supplemented.     

肉眼观察法在宫颈癌及癌前病变筛查中的应用

目的：探讨醋酸肉眼观察（VIA）和碘染色肉眼观察（VILI）在宫颈癌及癌前病变筛查中的可行性。方法：以天津市大港区2003例妇女为研究对象,进行癌症综合知识、危险因素的问卷调查．用VIA和VILI行宫颈癌及其癌前病变筛查。VIA或VILI阳性者行电子阴道镜检查,阴道镜检查异常者行阴道镜下宫颈活检,病理学检查明确诊断。结果：单纯VIA阳性者257例。VIA或VILI阳性者共计265例．其中197例阴道镜检查异常,在阴道镜指导下行宫颈活检,以病理学检查结果作为诊断的金标准,宫颈上皮内瘤变（CIN）的检出率为7．04％,其中CINI116例,CINⅡ14例,CINIII11例。结论：在资源有限、经济欠发达的地区,由经过培训的医生实施VIA或VIU做宫颈癌初筛的方案可行。     

肉眼观察法在宫颈癌及癌前病变筛查中的应用

目的：探讨醋酸肉眼观察（VIA）和碘染色肉眼观察（VILI）在宫颈癌及癌前病变筛查中的可行性。方法：以天津市大港区2 003例妇女为研究对象,进行癌症综合知识、危险因素的问卷调查,用VIA和 VILI行宫颈癌及其癌前病变筛查。VIA或VILI阳性者行电子阴道镜检查,阴道镜检查异常者行阴道镜下宫颈活检,病理学检查明确诊断。结果：单纯VIA阳性者257例,VIA或VILI阳性者共计265例,其中197例阴道镜检查异常,在阴道镜指导下行宫颈活检,以病理学检查结果作为诊断的金标准,宫颈上皮内瘤变（CIN）的检出率为7.04%,其中CINⅠ116例,CINⅡ14例,CINⅢ11例。结论：在资源有限、经济欠发达的地区,由经过培训的医生实施VIA或VILI做宫颈癌初筛的方案可行。     

紫杉醇化疗在宫颈癌中的临床应用

紫杉醇为广谱有效的抗实体瘤药物,用于宫颈癌患者治疗已进行广泛临床研究,证实其可靠有效。从单药、双药及三药化疗等方面,综述近年紫杉醇治疗宫颈癌的临床应用。紫杉醇（T）联合顺铂（P）或卡铂（C）化疗方案优于紫杉醇单药或三药化疗,安全有效。尤其在新辅助化疗中;与顺铂相比,卡铂肾毒性小,无需水化,TC方案相对简单;TP或TC配合放疗疗效显著;紫杉醇周疗与3周疗法比较疗效类似,不良反应较小。     

紫杉醇化疗在宫颈癌中的临床应用

紫杉醇为广谱有效的抗实体瘤药物,用于宫颈癌患者治疗已进行广泛临床研究,证实其可靠有效。从单药、双药及三药化疗等方面,综述近年紫杉醇治疗宫颈癌的临床应用。紫杉醇（T）联合顺铂（P）或卡铂（C）化疗方案优于紫杉醇单药或三药化疗,安全有效。尤其在新辅助化疗中;与顺铂相比,卡铂肾毒性小,无需水化,TC方案相对简单;TP或TC配合放疗疗效显著;紫杉醇周疗与3周疗法比较疗效类似,不良反应较小。     

Cervical Cancer Screening in Immunocompromised Women

In the context of changing recommendations for cervical cancer screening, differing recommendations in each province, and a lack of guidance for cervical screening of immunocompromised women, this article provides specific recommendations for cervical cancer screening of immunocompromised women in Canada.     

对ASCCP 2012年宫颈癌筛查和癌前病变管理指南的解读

针对子宫颈癌筛查过程中的细胞学及高危人乳头瘤病毒(HPV)阳性等的管理措施,美国阴道镜检查和宫颈病理学会(ASCCP)所制定的指南无疑是最具有国际性及权威性的。ASCCP于2013年公布的《2012年宫颈癌筛查和癌前病变全球共识指南》是由众多子宫颈癌防治专家组成的委员会通过搜集资料、研究文献、网上会议讨论等方式制定的,是对2006年版指南的更新和补充。其中,美国北加州凯瑟永久医疗集团(KPNC)140万例妇女2003年1月—2010年12月的筛查和随访资料为指南的制定提供了重要的循证医学证据。解读该指南,旨在了解指南修订的思路与循证医学证据,为合理处理宫颈癌异常筛查结果提供帮助。     

宫颈癌新辅助化疗临床研究现状

新辅助化疗是指在局部治疗（手术或放疗）前给予的全身化疗。近二十余年来国内外学者对宫颈癌新辅助化疗联合手术或放疗的治疗模式进行了一些探索,取得一定经验。但新辅助化疗在宫颈癌治疗中的地位仍未明确,且对其化疗方案选择目前无统一认识。对新辅助化疗在宫颈癌治疗方面的最新进展、多种新辅助化疗方案应用于宫颈癌的疗效及其发展趋势做综述。     

阴道镜下宫颈活检的准确性及宫颈癌漏诊相关因素分析

目的:探讨阴道镜下宫颈活检诊断宫颈上皮内瘤变(CIN)的准确性及其漏诊宫颈癌的相关因素分析。方法:回顾性分析阴道镜下宫颈活检确诊的587例CIN患者临床资料,均行宫颈LEEP术,以术后病理检查为金标准,观察阴道镜下宫颈活检CIN的准确性,并采用单因素及Logistic回归分析影响宫颈癌漏诊的相关因素。结果:587例患者阴道镜下活检与LEEP术后病理检查符合率为78.2%,病理级别上升50例(8.5%),其中漏诊浸润癌29例。术后提示病理降级的有78例(13.3%)。单因素分析显示:年龄≥55岁、阴道镜图像不满意、宫颈病变面积1/2者宫颈癌漏诊率较高,差异有统计学意义(P0.05),而HPV和TCT检测结果在影响宫颈癌漏诊率方面差异无统计学意义(P0.05)。Logistic回归分析示:年龄≥55岁、阴道镜图像不满意、宫颈病变面积1/2者均与宫颈癌的漏诊相关(P0.05)。结论:阴道镜检查对CIN的诊断存在一定的不准确性,可导致宫颈癌的误诊,提高临床医师对阴道镜的操作技能,积极多点活检,尤其关注阴道镜图像不满意患者和老年妇女是降低宫颈癌漏诊率的关键。     

宫颈癌新辅助化疗临床研究现状

新辅助化疗是指在局部治疗（手术或放疗）前给予的全身化疗。近二十余年来国内外学者对宫颈癌新辅助化疗联合手术或放疗 的治疗模式进行了一些探索,取得一定经验。但新辅助化疗在宫颈癌治疗中的地位仍未明确,且对其化疗方案选择目前无统一认识。对新辅助化 疗在宫颈癌治疗方面的最新进展、多种新辅助化疗方案应用于宫颈癌的疗效及其发展趋势做综述。     

The Impact of Obesity on Gynecologic Cancer Screening: An Integrative Literature Review

Introduction : Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening. Methods : A literature search of standard computerized databases was conducted for peer‐reviewed articles published between 1950 and January 2009. Results : Twenty‐three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient–provider communication. Discussion : Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women. J Midwifery Womens Health 2010;55:344–356 © 2010 by the American College of Nurse‐Midwives.