Cervical Cytology Screening Programme Research Articles

Addressing the Global Challenge: Strategies for Cervical Prevention and Early Detection within WHO's 90-70-90 Framework

Cervical cancer represents a substantial global health issue, standing as the third most prevalent cancer globally and the principal cause of cancer-associated mortality in women, with an uneven burden shouldered by less developed countries. Despite being the most preventable malignancy, with nearly all cases attributed to HPV infection, which has a lifetime cumulative risk of 80% through sexual transmission, cervical cancer remains a pressing issue. National cervical cytology screening programs have been implemented to identify cervical abnormalities, lesions, and early malignancies in eligible women. However, the utilization of screening techniques is declining, and due to resource constraints, screening schemes have not been adopted in less-developed economies. Several nations have embraced alternative screening techniques, such as Visual Inspection with Acetic Acid (VIA), which have shown impacts on mortality and morbidity rates. With the rising accessibility of efficacious HPV screening and self-testing, there will be a necessity to reconfigure existing cervical screening programs. Furthermore, preventative HPV vaccination is an integral part of the World Health Organization’s (WHO) Global Strategy to Expedite the Eradication of Cervical Cancer as a Public Health Issue, necessitating the restructuring of vaccination endeavors. This review article evaluates potential techniques for detecting precancerous lesions within the context of the WHO's 90-70-90 global policy for cervical cancer prevention and early diagnosis. The incidence and mortality rates are examined, highlighting the effectiveness of cervical cancer prevention efforts.

The Impact of Tamoxifen Usage in Breast Cancer Patients on the Development of Histopathological Lesions in the Cervix Uteri.

Background and Objectives: The purpose of the present study was to compare the results of colposcopic biopsies in patients with breast cancer and those who tested positive for HPV in cervix uteri cytological screenings, with a control group of HPV-positive individuals without breast cancer. Additionally, through this study, we aimed to investigate the impact of tamoxifen treatment, an anti-oestrogen drug used following breast cancer treatment, on histopathological changes. Breast cancer is the most common type of cancer and cause of death in women worldwide. Cervical cancer ranks as the second most prevalent form of cancer among women globally, with prevalence rates ranking just behind those of breast cancer. Human papillomavirus (HPV) positivity is a requirement for the development of cervical cancer, although it is not the sole factor responsible. Materials and Methods: A comparison was made between the histopathological results of 52 patients diagnosed with breast cancer, who tested positive for HPV in routine cervical cytological screenings and underwent colposcopic biopsy, and 230 cases without any abnormalities. A study was conducted to compare healthy individuals between the ages of 30 and 65 who were diagnosed with breast cancer and those who did not have breast cancer. The participants underwent HPV screening as part of the national cervical cytology screening programme. Results: The average age of those diagnosed with breast cancer was 46.73 ± 7.54; in comparison, the average age of participants in the control group was 47.49 ± 7.95. There was no statistically significant difference in age between the two groups (p: 0.530). A total of 51 cases (98.1%) of breast cancer were found to have actively used the anti-oestrogen drug tamoxifen for a duration ranging from at least 6 months to 5 years. One patient (1.9%) in the breast cancer group did not use tamoxifen. During routine cervical cytological screenings, it was observed that both breast cancer cases and healthy cases tested positive for HPV. The most commonly detected types of HPV in both groups were HPV 16 and 18, with rates of 73.1% noted in the breast cancer group and 92.6% noted in the healthy group, results consistent with the rates found in the general population. HPV 16 was found in 58.7% of participants in the control group and 42.3% of participants in the breast cancer group. There was a statistically significant difference between the two groups (p: 0.032). There was no statistically significant difference observed between the two groups in terms of normal, high-grade cervical intraepithelial lesions (HGSILs); low-grade cervical intraepithelial lesions (LGSILs); and chronic cervicitis histopathological lesions based on colposcopic and endocervical biopsy results, smear cytology, and HPV results (p-values of 0.913 and 0.877, respectively). Conclusions: Our study results indicate that tamoxifen treatment, an anti-oestrogen drug administered for chemoprevention purposes in the management of breast cancer, does not lead to an increase in abnormal histological changes in the cervix uteri. In all cases of breast cancer, gynaecological examination and cervical cytological screening should be advised.

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Spotlight on… mental health

Impact of replacing cytology with human papillomavirus testing for cervical cancer screening on the prevalence of Trichomonas vaginalis: a modelling study

ObjectivesTrichomonas vaginalis (TV) is the most common curable STI worldwide and is associated with increased risk of HIV acquisition and serious reproductive morbidities. The prevalence of TV infection is very...

Single life time cytological screening in high risk women as an economical and feasible approach to control cervical cancer in developing countries like India.

In view of funding crunches and inadequate manpower in cytology in developing countries like India, single lifetime screening for cervical cancer has been suggested. In this study, an attempt was made to identify high risk groups of women for this screening to make it more effective for early detection. Cytological data were derived from the ongoing routine cervical cytology screening program for women attending Gynaecology Out Patient Department of Queen Mary's Hospital of K.G.Medical University, Lucknow, India during a span of 35 years (April 1971 - December 2005). Cervical smears in a total of 38,256 women were cytologically evaluated. The frequencies of squamous intraepithelial lesions of cervix (SIL) and carcinoma cervix were found to be 7.0% and 0.6%, respectively, in the series. Predisposing factors related to cervical carcinogenesis were analyzed in detail to establish the most vulnerable groups of women for single life time screening. The incidence of SIL and carcinoma cervix was found to be maximal in women above the age of 40 years irrespective of parity and in multiparous women (with three or more children) irrespective of age. The incidence of cervical cytopathologies was significantly higher in symptomatic women, the frequency of SIL being alarmingly higher in women complaining of contact bleeding and that of carcinoma cervix in older women with postmenopausal bleeding. It is consequently felt that single life time screening must include the three groups of women delineated above. Such selective screening appears to be the most economical, cost effective and feasible approach to affordably control the menace of cervical cancer in developing countries like India.

Prevalence of high-risk human papillomavirus (HR-HPV) infection among women with normal and abnormal cervical cytology in Myanmar.

This study aimed to determine the prevalence of normal and abnormal cervical cytology in women who attended the cervical cancer screening clinic of the Department of Medical Research in Lower Myanmar, and to determine the proportion of high-risk (HR) human papillomavirus (HPV) infection and HPV genotypes in women with normal and abnormal cervical cytology. A total of 1,771 women were screened from 2010 to 2011. Among them, 762 women (43.0%) had a normal smear, and 866(48.9%) and 87 (4.9%) were diagnosed with inflammatory smears and atypical squamous cells of undetermined significance (ASCUS), respectively. Diagnoses of low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL) numbered 42 (2.3%) and 11 (0.6%) respectively. Three cases of squamous cell carcinoma (SCC) (0.2%) were detected. Cervical swabs were collected from 96 women with abnormal cervical cytology and 20 with normal cytology. HR-HPV DNA testing was performed by polymerase chain reaction (PCR) with pU1M/pU2R primers. HR-HPV were identified in 35.5% (22/62) of inflammatory smears, 60% (6/10) of ASCUS, 86.7% (13/15) of LSIL, 50% (3/6) of HSIL, 100% (3/3) of SCC and 5% (1/20) of normal cytology. In PCR-positive cases, HPV genotyping was analyzed by the cleaved amplification polymorphism method. The most prevalent HPV genotypes were HPV-16 (60.4%) followed by HPV-31 (14.6%), HPV-18 (12.5%) and HPV-58 (12.5%). Women with abnormal cervical cytology were 10 times more likely to be HR-HPV positive than those with normal cytology (p=0.0001). This study suggests that the implementation of a cervical cytology screening program and routine vaccination against HPV in preadolescent and adolescent groups are needed to reduce the burden of HPV-associated cervical cancer.

Screening for Cervical Cancer in Low-Resource Settings in 2011

Cervical cancer remains the most common malignancy in women living in low- and middle-income countries, despite the decline of the disease in countries where cervical cytology screening programs have been implemented. To review the current incidence of cervical cancer in low-resource countries, the availability and types of screening programs, and the treatment options. Literature review through PubMed, Internet search, and personal communication. Although data are incomplete, available figures confirm that the rate of cervical cancer deaths and the availability of cervical cancer screening programs are inversely proportional and vary, in general, by the wealth of the nation. Despite the success of cervical cytology screening, many major health care organizations have abandoned screening by cytology in favor of direct visualization methods with immediate treatment of lesions by cryotherapy provided by trained, nonmedical personnel.

Cervical cytology screening programs: Similarities and differences between the United States and United Kingdom systems

The United States and United Kingdom have cervical cancer screening programs that developed many similar and contrasting characteristics based on circumstances unique to each society. These features, their origins, and potential futures are presented.

Cancer screening of the uterine cervix papanicolaou smears versus state‐of‐the‐art human papillomavirus testing

The article by Albrow et al in this issue describes the early cervical screening program in England as being "disorganized," but goes on to describe significant improvements over 20 years. It has become one of the leading screening programs in the developed world. Liquid-based technology has been embraced, but image analysis has not. The key ingredient for the NHSCSP's success is quality assurance. The scrutiny given to medical interventions has increased recently. Would the early cervical cancer cytology screening programs have passed muster if they had required this sort of validation? Using information from the Victorian Cytology Screening Services Melbourne and other Australian screening programs to guide its formulation, Australia's evidence-based program differs from the NHSCSP in several ways. The screening interval is 2 years, liquid-based technology is not funded, and human papillomavirus (HPV)-DNA testing for the triage of atypical lesions has not been sanctioned in Australia. Albrow et al allude to the possible introduction in the future of HPV-DNA testing as a primary screening tool. Cancer (Cancer Cytopathol) 2012;. © 2012 American Cancer Society.

Fatal invasive cervical cancer secondary to untreated cervical dysplasia: a case report

IntroductionWell-documented cases of untreated cervical intra-epithelial dysplasia resulting in fatal progression of invasive cervical cancer are scarce because of a long pre-invasive state, the availability of cervical cytology screening programs, and the efficacy of the treatment of both pre-invasive and early-stage invasive lesions.Case presentationWe present a well-documented case of a 29-year-old Caucasian woman who was found, through routine conventional cervical cytology screening, to have pathologic Papanicolaou (Pap) grade III D lesions (squamous cell abnormalities). She subsequently died as a result of human papillomavirus type 18-associated cervical cancer after she refused all recommended curative therapeutic procedures over a period of 13 years.ConclusionThis case clearly demonstrates a caveat against the promotion and use of complementary alternative medicine as pseudo-immunologic approaches outside evidence-based medicine paths. It also demonstrates the impact of the individualized demands in diagnosis, treatment and palliative care of patients with advanced cancer express their will to refuse evidence-based treatment recommendations.

Management of gynecologic patients with precancerous disease

부인암 중 자궁경부암은 예방이 가능한 암으로 알려져 있는데, 전암 병변에서 장기간에 걸쳐 서서히 침윤성 암으로 진행하게 되므로 선별검사를 통한 조기 진단 및 치료가 효과적이기 때문이다. 전암 병변을 제대로 치료하지 못하면 침윤암의 위험을 증가시키고, 반대로 불필요할 정도로 과도하게 치료하면 합병증을 증가시킬 수 있기 때문에, 전암 병변을 적절하게 치료하는 것이 중요하다. 환자 개개인별로 치료방법을 선택할 때에는 환자의 나이, 출산경력, 나중에 아이를 갖고자 하는 열망, 선호도, 이전 세포검사 결과와 치료병력, 추적검사 중에 문제가 있었는지 여부, 수술자의 경험, 변형층 (transformation zone)이 보이지 않는 경우 등과 같은 사항을 고려한다.

Anal–rectal cytology: A review

The incidence of invasive anal squamous cell carcinoma, a human papilloma virus (HPV) related cancer, is on the rise, especially in HIV positive men who have sex with men (MSM). Like cervical cancer, anal cancer is associated with precursor lesions detectable on exfoliative cytology as squamous intraepithelial lesions and on biopsy as intraepithelial neoplasia. Anal-rectal cytology screening programs, similar to cervical cytology screening programs, have been developed in an effort to detect and to eradicate precursor lesions prior to progression to invasive squamous cell carcinoma. Either conventional or liquid-based anal-rectal cytology specimens are acceptable, but liquid-based specimens are preferred. Specimens may be collected by health care professionals or by patients. A minimum of 2,000-3,000 nucleate squamous cells should comprise adequate specimens. Diagnostic terminology as defined by the Bethesda System for Reporting Cervical Cytology (TBS 2001) should be used. Sensitivity and specificity of a single anal-rectal cytology specimen is comparable with that of a single cervical cytology test, but cytological interpretations do not always correlate with lesion severity. Patients with atypical squamous cells of undetermined significance (ASC-US) or worse should be referred for anoscopy.

HPV-related disease in Indigenous health

Cervical cancer is the second most common cancer in women worldwide, with the majority of cases occurring in the developing world. With effective high-quality cervical cytology screening programs, with wide coverage of target populations, precursor lesions can be detected and treated, ultimately preventing progression to the development of cervix cancer.

Human Papillomavirus and Cervical Cancer in Australasia and Oceania: Risk-factors, Epidemiology and Prevention

The region encompassing Australasia and Oceania, including Australia, New Zealand, Fiji and Papua New Guinea, is a diverse one with respect to ethnicities, cultures and behaviours. It includes countries with comprehensive cervical cytology screening programmes which can be credited with significant reductions in cervical cancer incidence and mortality, and countries with no prevention programmes and significantly higher incidence and mortality. As elsewhere in the world, human papillomavirus (HPV)-16 and 18 are the commonest high-risk types, with the highest rates in women under 25 years of age. These two high-risk HPV types are found most frequently in cervical cancers and high-grade dysplasias, although there are minimal data for many countries in Oceania. In April 2007, Australia became the first country worldwide to commence a government funded universal HPV vaccine programme. The school-based programme targets 12-year old females in an ongoing schedule, with a catch-up programme up to 26 years of age, to be completed in mid-2009. Vaccine introduction has been comprehensively rolled out, with around 75% uptake of the complete vaccine schedule among school-girls in the first year of this initiative. This represents a successful model for other countries. We present data on cervical cancer, risk factors and prevention strategies, including epidemiology of HPV and HPV vaccine strategies.

Impact of colposcopy on management outcomes of patients with abnormal cervical cytology

With stringent cervical cytology screening programmes for women in reproductive age group, cervical cancer is, to a large extent, preventable. Back-up confirmatory colposcopic evaluation is necessary in order for cytology to have impact on cervical cancer-related morbidity and mortality. To track the management outcomes of abnormal cervical cytology and hence confer credence to the value of colposcopy in management of abnormal cervical cytology. Retrospective descriptive study. Kenya Medical Women Association Colposcopy Clinic. Correlation of cervical cytologic abnormalities with colposcopic outcomes and eventual management outcomes. The population was young, with 50.6% being 25-34 years old, and 59.3% less than 35 years of age. Parity was also low, with nearly 75% being para three or less. A substantial proportion of women had normal colposcopic findings (42.0, 26.7,18.6 and 11.1% for cytologic abnormalities CIN I, CIN II, CIN III and invasive carcinoma respectively). Colposcopic abnormality detection rate, irrespective of the severity of the lesion, increased with severity of cytologic lesion (from 58.0% CIN I to 89.0% for invasive carcinoma). The sensitivity of cervical cytology was 58, 59 and 65% for CIN I,II and III respectively, while respective specificity was 72, 71 and 85%. The concordance rates between cytological and colposcopic findings were 38.6, 32.5 and 60% for CIN I, II and III respectively. The eventual management outcome was operative (LEEP and Hysterectomy) in greater frequency as the severity of the cytologic lesion increased. Colposcopy has significant impact on the management outcomes of abnormal cervical cytology and is therefore an invaluable procedure in management of abnormal cervical cytology. For this reason, it is imperative that governments avail these services to all women, in addition to enforcing regular cytologic screening for cervical cancer.

Outcome of “Atypical squamous cells” in a cervical cytology screening program: Implications for follow up in resource limited settings

(1) To study the incidence and outcome of "Atypical squamous cells (ASC)" diagnosis in a hospital based cytology screening programme. (2) To work out a feasible strategy for follow up of Atypical squamous cells-undetermined significance (ASC-US) and Atypical squamous cells-cannot exclude high grade squamous intraepithelial lesion (ASC-H) in resource limited settings. A total of 29,475 women were screened cytologically through Pap tests. The epithelial cell abnormalities (ECA) detected on screening were reviewed by the cytopathologists and classified according to Bethesda 2001 system. The women with ASC-US reports were followed up by two repeat cytology tests at 3 and 6 months of the initial visit. The persistent ASC-US cases or the cases which revealed squamous intraepithelial lesion (SIL) on follow up smears; as well as all ASC-H and above cases were referred for coloposcopic evaluation. ASC diagnosis comprised 3.6% of all reports. These were qualified as ASC-US (3.36%) and ASC-H (0.22%). On follow up, only 7 CIN 2 or worse (3.2%) lesions were detected on 218 biopsies in ASC-US category while in ASC-H qualifier 16 CIN 2 and above lesions (30.8%) were picked up on 52 colposcopic biopsies. The difference between ASC-US and ASC-H categories for a CIN 2 or worse outcome was highly significant (P < 0.001). ASC-H qualifier has a high likelihood for an ominous histological outcome and warrants an immediate colposcopic evaluation. On the other hand, ASC-US cases can be managed conservatively by repeat cytology tests at regular intervals without a significant risk of missing a high grade lesion. Diligent screening of cervical smears can judiciously downgrade some cases overcalled as ASC because of inflammatory atypia and thereby reduce referrals in geographic settings with high prevalence of reproductive tract infections. High risk HPV (HR HPV) testing may be a useful adjunct to further reduce referrals by selecting the women who require colposcopic evaluation.

Epidemiology of Cervical Cancer

nvasive cancer of the cervix is considered a preventable disease because it has a long pre� invasive state, cervical cytology screening programs are currently available, and the treatment of preinvasive lesions is effective. Cancer of the cervix is the second most common cancer among women worldwide, with an estimated 493,000 new cases and 274,000 deaths in 2002. The highest incidence rates are observed in subSaharan Africa, Melanesia, Latin America and the Caribbean, SouthCentral Asia, and South East Asia. In Korea, cervical cancer is the fifth most common cancer among women with over 3,000 new cases every year. Agestandardized incidence rate (ASR) is 15.5 per 100,000, which is lower than those in developing countries but higher than in western countries such as Europe and North America. The patients' mean parity is 2.59, and the range of age in peak incidence is 40~49 years (29.8%), followed by 50~59 years (21.9%). As the age goes on, more advanced stage cancer is frequent. Squamous cell carcinoma is the most common cell type, and adenocarcinoma is more frequent among those under 60 years old. Operation (56.0%) is the major treatment modality under stage IIa, and concurrent chemoradiation (31.6%) is the major treatment over stage IIb. The 5year survival rate is 73.9%. It is generally thought that human papillomavirus (HPV) test and HPV vaccine might play an important role in lowering the incidence of cervical cancer, and continuous epidemiologic studies will support its usefulness and efficacy. Abstract

52. THE AUSTRALIAN WOMEN'S HEALTH SURVEY: ASSESSING THE PSYCHOSOCIAL BURDEN OF HPV RELATED ILLNESS AND PREVENTIVE INTERVENTIONS

There is increasing recognition of the psychosocial impact of cervical cytology screening programs as well as of the treatment of screening-detected human papillomavirus (HPV) - related disease. The HPV Impact Profile (HIP) includes 29 items with standard response categories representing nine psychosocial impact domains: 'worries and concerns, emotional impact, sexual impact, self image, health perception, cognition, partner and social relations, interaction with doctors and sleep'. Higher scores (0-100) are associated with higher disease burden. The HIP and other generic quality of life instruments such as the Sheehan Disability Scale were administered to women who had experienced and were aware of an HPV related diagnosis in the past 3 months (total n�=�333): 103 women with normal Pap test results (N. Pap), 111 with abnormal Pap tests (58 low grade squamous intraepithelial lesions (LSIL) and 53 high grade SIL (HSIL)), 80 women with biopsy confirmed cervical intraepithelial neoplasia (CIN) (36 CIN1 and 44 CIN 2/3) and 39 women with external genital warts (EGW). In univariate analysis, estimated HIP scores (95% CI) were lower for N.Pap than for all other groups (p�&lt;�0.0001), N. Pap: 25.8 (22.6-29.0); LSIL: 38.8 (34.6-43.1); HSIL: 41.7 (37.2-46.2); CIN1: 41.7 (36.3-47.1); CIN 2/3: 46.6 (41.6-51.5) (p�=�0.013 vs LSIL); EGW: 44.6 (39.4-49.8). The effect was maintained after adjusting for age, race and occupation. On the Sheehan scale, CIN 2/3 and EGW demonstrated increased interference with work and social activities. Results demonstrate: a) HPV infection and disease are associated with significantly increased psychosocial burden, beyond that of the Pap test experience; b) The HIP instrument can adequately distinguish between different HPV conditions; c) Despite their non life threatening nature, the psychosocial impact of genital warts is similar to that of potentially life threatening high grade cervical lesions.

Cervical cytology testing in teens

Although cervical cytology screening programs have dramatically decreased rates of invasive cancer in developed countries, most guidelines in the USA were overaggressive in their management of abnormal cytology in adolescents and young women. These management strategies resulted in costly over-treatment. The purpose of this article is to review the evidence for the new guidelines in cytology screening in youth. Natural history studies of human papillomavirus (the cause of abnormal cytology and cervical cancer) suggest there is little risk of a significant pre-cancerous lesion going undetected within the first 3-5 years after the onset of sexual activity. The American Cancer Society now recommends that screening be initiated within 3 years of the onset of vaginal intercourse but no later than 21 years of age. The American Society for Colposcopy and Cervical Pathology allows for follow-up of low-grade squamous intra-epithelial lesions with repeat cytology or human papillomavirus DNA testing rather than immediate referral to colposcopy. The new recommendations appear to be safe and will decrease the current over-referral and over-treatment of adolescents and young women with HPV infections.

Effective cervical cytology screening programmes in middle-income countries: The Chilean experience

Objective: To demonstrate that an effective cervical cancer screening programme based on the Papanicolaou (Pap) smear can be organized in a middle-income country, such as Chile. Methods: The cervical cytology screening programme in Chile is evaluated by comparing process measures and cervical cancer mortality before and after its reorganization in 1987. Findings: Two decades of opportunistic annual screening for cervical cancer from the mid-1960s to the mid-1980s did not reduce cervical cancer mortality in Chile. In 1987, a public health oriented program was launched, based on screening women aged 25–64 every 3 years, rather than the annual screening of low risk women attending family planning clinics that gathered mainly women less than 25 years of age. The reoriented program emphasized the optimization of existing resources, the timeliness of diagnosis and treatment, reliability of the Pap smear and low cost screening promotion strategies at the community level. More than 80% of women with abnormal Pap smears received prompt medical attention and 100% of the public laboratories were subject to external quality control. According to biannual national surveys, coverage by Pap smear screening in the target group rose from 40% in 1990 to 66% in 1996. The age adjusted cervical cancer mortality rate decreased from 12.8 in 1980 to 6.8 per 100,000 women in 2001. Conclusions: Improved organization of the national cervical cancer screening programme in Chile and more efficient use of existing resources resulted in a decrease of cervical cancer mortality.