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Abstract

We appreciate the thoughtful comments by Dr Jargin on our manuscript.1Herzog T.J. Monk B.J. Reducing the burden of glandular carcinomas of the uterine cervix.Am J Obstet Gynecol. 2007; 197: 566-571Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Dr Jargin reviews the well-documented failures and complexities of screening for cervical cancer using cytology alone in Russia. It is important to note that much of our manuscript focused on the US particulars of glandular cervical carcinomas; however, we fully recognize the global struggle that our colleagues abroad face in detecting and treating all types of cervical cancer. Clearly, for Papanicolaou testing to be effective in reducing the incidence and mortality from cervical cancer in any region of the world, close cooperation among the primary care physician, gynecologist, oncologist, pathologist, and patient is necessary. In addition, sufficient health care resources are required to perform appropriate ablation of preinvasive and invasive lesions. Besides cervical cytology, 3 other means of cervical cancer prevention deserve comment. First, widespread human papillomavirus (HPV) vaccination appears to be the most effective and cost-sensitive approach to preventing HPV-related precancers and malignancies, including cervical carcinomas in general and glandular cancers specifically,2Monk B.J. Herzog T.J. The evolution of cost-effective screening and prevention of cervical carcinoma: implications of the 2006 consensus guidelines and human papillomavirus vaccination.Am J Obstet Gynecol. 2007; 197: 337-339Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar particularly in low-recourse settings. Second, HPV deoxyribonucleic acid (DNA) testing is emerging as another potential method of screening for cervical cancer. However, the use of HPV DNA testing for the secondary prevention of cervical cancer in regions such as Russia will still require pathologists to accurately interpret Papanicolaou smears and biopsies and clinicians capable of performing colposcopies, biopsies, and ablative techniques. Indeed, many of the barriers outlined by Dr Jargin for the effective use of cytology also apply to widespread HPV testing, making this a very challenging endeavor. However, using HPV DNA testing as a method to triage minimally abnormal Papanicolaou smears (eg, atypical squamous cells of undetermined significance) could greatly reduce the health care burden of evaluating abnormal Papanicolaou smears in countries such as Russia. HPV DNA testing could also aid in clarifying the significance of Papanicolaou smears read as squamous metaplasia or reserve-cell hyperplasia, as mentioned by Dr Jargin. Third, Dr Jargin states that “a radical preventive measure must not be the screening but improvement of morality.” Presumably, Dr Jargin is implying that changes in sexual practices, particularly increasing monogamy, are likely to reduce the incidence and mortality of cervical cancer in Russia. Certainly an increase in the number of sexual partners escalates one's chance of becoming infected with HPV and is associated with an increased risk of cervical neoplasia.3International Collaboration of Epidemiological Studies of Cervical CancerComparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies.Int J Cancer. 2007; 120: 885-891Crossref PubMed Scopus (283) Google Scholar However, changing community morals is undoubtedly multifaceted, and this lofty goal is unlikely to impact society in its entirety. This would not improve the risk for disease among women already infected. Furthermore, the extremely high prevalence of HPV in the population puts all sexually active women at risk, regardless of their behavior. Patient educational initiatives and advocacy for responsible behavior are not mutually exclusive to the development of effective screening and prevention programs. In fact, these important efforts are complementary. Thus, cervical cancer screening should continue, even in Russia, and efforts should be made to overcome barriers to screening, as discussed by Dr Jargin. Increasing morality is an appropriate and laudatory goal, but the most efficient way to decrease the cost and morbidity from cervical cancer is immunization against cancer-causing HPV types. Perspectives of cervical cytology in RussiaAmerican Journal of Obstetrics & GynecologyVol. 199Issue 2PreviewWidespread use of the Papanicolaou test for the screening of cervical cancers has led to a significant decline in overall incidence and mortality rates over the past 3 decades.1 This statement from the article by Herzog and Monk1 is true for many countries but not for Russia. During Soviet time, yearly medical examinations were performed in many institutions and factories, which were often only a formality; cervical smears were taken but mostly for bacteriological diagnosis. Full-Text PDF