Cervical Screening Practices Research Articles

High-risk human papillomavirus infection among women with pap smear tests negative for intraepithelial lesions or malignancy

Cervical cancer is one of the most common cancers in United Arab Emirates (UAE) as well as in the world; high-risk human papillomavirus (HR-HPV) infection is found to be the most common cause of cervical cancer. The objective of the study is to evaluate the status of HR-HPV infection among women with Pap smear tests negative for intraepithelial lesions/malignancy (NILM). This cross-sectional study was conducted at the GMC Hospital and Gulf Medical University Histopathology/Cytology and Molecular Biology Laboratories within a period of 6 months from December 2011-May 2012. All pertinent patients' data were obtained from medical records. A total of 50 patients were included in the study. Cytology (PreservCyt) samples were tested for HR-HPV, using the polymerase chain reaction (PCR) based test AMPLICOR HPV. This test is designed to detect 13 HR-HPV type. Data was analyzed using the Statistical Package for Social Sciences (SPSS) software package and was presented mainly as percentages of total sample size. Results: Of the 50 patients, five (10%) were positive for HR-HPV. Only four patients out of the 50 patients (8%) underwent Pap smear test as voluntary routine check-up, while 46 patients (92%) underwent the test because they were symptomatic. Conclusions: We acknowledge the small size of our working sample, but in view of very limited data in the region and due to strong cultural taboos against the topic, we have drawn some high level statistical conclusion and found that a moderately high prevalence of HR-HPV positive patients among women with Pap smear test NILM was detected in UAE, a country where no community based cervical cancer screening program is practiced. The rate of opportunistic/voluntary cervical screening was very low indicating poor or lack of awareness about the importance of Pap smear test as a tool to screen cervical epithelial changes among study population. The results presented in this study may provide valuable data for physicians involved in decision-making regarding the current situation related to cervical screening practice and HPV infection in UAE.

The burden and costs of prevention and management of genital disease caused by HPV in women: A population-based registry study in Finland

The aim of this study was to evaluate the total burden and health care provider costs of prevention, management and treatment of HP-related genital disease outcomes including all organized and opportunistic screening tests. Information about HPV-related disease outcomes in the Finnish female population of 2.7 million was obtained from nationwide population-based registry data. We estimated the incidence, health care resource use, health provider costs and life years lost due to cervical, vaginal and vulvar cancer and intraepithelial neoplasia (CIN, VaIN, VIN), cervical adenocarcinoma in situ, and external genital warts. The average annual disease burden of HPV-related genital disease in the female population of Finland comprises altogether 241 cases of cervical, vaginal and vulvar cancer, 2,898 new cases of CIN, 34,432 cases of minor cytological abnormalities, and almost 4,000 cases of external genital warts. The total annual costs of screening, further diagnostics and treatment of HPV-related genital disease were € 44.7 million of which the annual costs due to cervical cancer screening were € 22.4 million and due to diagnostics, management and treatment of HPV-related genital disease outcomes were € 22.3 million. The latter included € 8.4 million due to minor cervical abnormalities detected by the current cervical screening practice. The extensive opportunistic Pap testing fails to keep the incidence of cervical cancer from increasing among women aged 30-34. In addition opportunistic screening among this and younger age group detects a significant number of cytological abnormalities, most of which are probably treated unnecessarily.

Cervical screening uptake and its predictors among rural women in Malaysia

Cervical cancer is the third most common cancer among Malaysian women. However, the uptake of cervical cancer screening--Pap smear--by women in Malaysia has been low and remains a challenge. This study was conducted to assess the cervical screening practices of rural women in Malaysia and to examine the factors associated with such practices. A cross-sectional survey was conducted in five rural districts in Perak, Malaysia. 1,000 households were selected through multistage random sampling. Women aged 20-64 years were interviewed by trained enumerators using structured questionnaires. Binomial logistic regression was used to identify predictors of cervical screening through univariate and multivariate analyses. Among the 959 respondents, only 48.9% had undergone Pap smear at least once in the past three years. Women in the age group 40-49 years (odds ratio 3.027, 95% confidence interval 1.546-5.925; p < 0.005) were found to be significantly more likely to attend cervical cancer screening as compared to those in the age group 20-29 years. Other significant predictors were being married with children, having knowledge of cervical cancer symptoms, receiving relevant information regarding cervical cancer from health personnel or campaigns, being engaged in family planning and receiving encouragement from husbands. Efforts to boost the uptake of Pap smear screening among the rural population should be targeted toward the predictors of positive uptake.

Correlates between risk perceptions of cervical cancer and screening practice

ObjectivesTo identify the correlates between risk perceptions and cervical cancer screening among urban Malaysian women. MethodA cross-sectional household survey was conducted among 231 women in Petaling Jaya city in 2007. The association of risk perceptions of cervical cancer and screening practice was analyzed using Poisson regression. Results56% of the respondents ever had a Pap smear test. Knowledge of signs and symptoms (aPR=1.11, 95% CI=1.03–1.19), age (aPR=1.02, 95% CI=1.01–1.03), number of pregnancies (aPR=1.06, 95% CI=1.01–1.11), marital status, education level and religion were found to be significant correlates of Pap smear screening. Respondents who were never married were less likely to have had a Pap smear. Those who had no education or primary education were less likely to have had a Pap smear compared to those with degree qualification. The prevalence of screening was significantly higher among Christians and others (aPR=1.35; 95% CI=1.01–1.81) and Buddhists (aPR=1.38; 95% CI=1.03–1.84), compared to Muslims. ConclusionEliminating anecdotal beliefs as risks via targeted knowledge on established risk factors and culturally sensitive screening processes are strategic for increasing and sustaining uptake of Pap smear screening versus current opportunistic screening practices.

Expenditure and resource utilisation for cervical screening in Australia

BackgroundThe National Cervical Screening Program in Australia currently recommends that women aged 18–69 years are screened with conventional cytology every 2 years. Publicly funded HPV vaccination was introduced in 2007, and partly as a consequence, a renewal of the screening program that includes a review of screening recommendations has recently been announced. This study aimed to provide a baseline for such a review by quantifying screening program resource utilisation and costs in 2010.MethodsA detailed model of current cervical screening practice in Australia was constructed and we used data from the Victorian Cervical Cytology Registry to model age-specific compliance with screening and follow-up. We applied model-derived rate estimates to the 2010 Australian female population to calculate costs and numbers of colposcopies, biopsies, treatments for precancer and cervical cancers in that year, assuming that the numbers of these procedures were not yet substantially impacted by vaccination.ResultsThe total cost of the screening program in 2010 (excluding administrative program overheads) was estimated to be A$194.8M. We estimated that a total of 1.7 million primary screening smears costing $96.7M were conducted, a further 188,900 smears costing $10.9M were conducted to follow-up low grade abnormalities, 70,900 colposcopy and 34,100 histological evaluations together costing $21.2M were conducted, and about 18,900 treatments for precancerous lesions were performed (including retreatments), associated with a cost of $45.5M for treatment and post-treatment follow-up. We also estimated that $20.5M was spent on work-up and treatment for approximately 761 women diagnosed with invasive cervical cancer. Overall, an estimated $23 was spent in 2010 for each adult woman in Australia on cervical screening program-related activities.ConclusionsApproximately half of the total cost of the screening program is spent on delivery of primary screening tests; but the introduction of HPV vaccination, new technologies, increasing the interval and changing the age range of screening is expected to have a substantial impact on this expenditure, as well as having some impact on follow-up and management costs. These estimates provide a benchmark for future assessment of the impact of changes to screening program recommendations to the costs of cervical screening in Australia.

Cross-sectional survey of the health behaviour of southeast Queensland women with cancer-treatment induced menopause: Implications for cancer and primary care nurses

PurposeWomen who experience cancer treatment-induced menopause are at risk of long-term chronic morbidity. This risk can be prevented or offset with adherence to health promotion and risk reduction guidelines. The purpose of this study was to explore health behaviours in younger female survivors of cancer and the variables (quality of life and psychological distress) believed to moderate health behaviours. DesignCross-sectional survey of a convenience sample of women (n=85) in southeast Queensland. MethodsHealth behaviour and health status were elicited with items from the Australian Health Survey and the Behavioural Risk Factor Surveillance System. The WHO Quality of Life (Brief) measured participants’ self-reported quality of life and their satisfaction with their health. The Brief Symptom Inventory-18 measured psychological distress. FindingsHigher self-reported health status was associated with regular exercise and better quality of life. However, a substantial proportion of participants did not engage in the physical activity, dietary or cervical screening practices recommended by Australian guidelines. ConclusionsThe participants require education regarding the benefits of diet, exercise, weight loss and decreased alcohol intake, as well as information on future health risks and possible comorbidities. These education sessions could be addressed by a nurse-led health promotion model of care at the time of discharge or in the community.

Gynecological screening or cervical screening? Conflicts between clinical and public health viewpoints

The "gynecological screening" that is composed of complex gynecological examination including colposcopy and cytological examinations has traditionally been incorporated into the gynecological protocol and practice. Over the past few decades, unfortunately, this screening practice has entrenched in the mind both of the gynecological community and the general public. As a result, the government-supported, organized cervical screening program of the population has come to a standstill. In order to adjust the cervical screening practice to the international public health recommendations in which cytology is the only screening test applied, the authors decided to involve primary care nurses and health visitors in smear taking, and to refer those with abnormal findings to a gynecologist for further clinical examination.

Healthcare spending in the case of a HPV16/18 population-wide vaccination programme

The policy of population-wide human papillomavirus (HPV) vaccination has been debated as the introduction of such a programme in a low-resource country faces the risk of insufficient cost-effectiveness. To assess the potential healthcare spending changes after the introduction of a HPV16/18 population-wide vaccination programme in Lithuania. For a cost-effectiveness analysis, we used mathematical simulation and epidemiological data modelling based on a Lithuanian female population. We performed comparative analysis of an annual 12-year-old girls population-wide vaccination programme combined with cervical cancer screening programme compared to the screening programme strategy only. HPV vaccination would gain an average of 35.6 life years per death avoided or up to 284.8 thousand life years would be gained over 90 years in total. The programme costs would be 2932.58 EUR per life year gained. All costs associated with the introduction of the vaccination programme could be recovered in 48 years. The HPV vaccination programme in Lithuania has the potential to generate up to 40.07 million EUR of economic returns annually compared with the current practice of the cervical screening alone. In Lithuania the HPV16/18 vaccination programme would be economically effective only in the long term. The investment costs of HPV16/18 vaccination have the potential to be recovered.

Increasing Mammography and Cervical Cancer Knowledge and Screening Behaviors With an Educational Program

To evaluate the effectiveness of using an educational program based on self-efficacy to increase knowledge and create behavior change regarding recommended mammography and Papanicolaou (Pap) test screening guidelines. Pretest and post-test, prospective. An urban county in northern Indiana. 56 women who attended one of four educational programs and 47 women who responded 15 months later. The one-hour educational programs based on self-efficacy included vicarious experiences and verbal persuasion regarding breast and cervical screening practices. Two programs were offered to local church groups as part of a health fair, and two were offered through health promotion initiatives sponsored by private businesses. Demographics, knowledge of breast and cervical cancer, and screening behaviors. Knowledge of risk and screening guidelines increased significantly immediately following the educational program (p < 0.001) and did not decrease significantly 15 months later (p = 0.57). Family history and history of human papillomavirus and sexually transmitted diseases were the top known risk factors for breast and cervical cancers, respectively. Participant-reported rates of screening behaviors increased 15 months later for mammography (100%) and Pap test (84%). Educational interventions based on self-efficacy increased knowledge of breast and cervical health and helped increase the rate of mammography and Pap tests. Preparing women with strategies to complete a mammogram and Pap test is an important approach to enhancing self-efficacy and increasing screening behaviors.

The risk of cervical cancer associated with specific types of human papillomavirus: A case–control study in a UK population

Mounting evidence supports incorporation of HPV testing into cervical screening; however, the optimal test format and target population have yet to be confirmed. Assessment of the potential benefits of type-specific testing requires estimation of the risk associated with infection with individual HPV types. However, the risk posed by individual HPV types may be population specific and influenced by cervical screening practice. The existing data on HPV type-specific risk is derived largely from unscreened populations. Our study addressed the lack of data on HPV type-specific risk in cytologically screened populations using a case-control study of 262 invasive cervical cancers diagnosed in Wales between 2000 and 2006, and 8,428 controls who attended for cytological screening in 2004. The analysis showed that the odds ratios (ORs) for infection with HPV 16 and 18 are considerable; 2770 (95% CI 1050-7320) and 950 (95% CI 330-2740), respectively, and that the OR for other oncogenic types are in general considerably less (ranging, where quantified, from 20.2 to 386 in the same population). The effect of age on OR associated with particular HPV types was also assessed; this indicated that infection with a high-risk HPV in women older than 40 years was associated with an approximately 30-fold increased risk of invasive cervical cancer relative to women younger than 40 years. These results indicate that there is significant prognostic information associated with knowledge of HPV type.

Knowledge of cervical cancer and screening practices of nurses at a regional hospital in Tanzania.

Cervical cancer, the most common cancer among women in Tanzania is strongly linked to Human Papilloma Virus. Precancerous lesions can be detected by Papanicolau smear screening. Nurses, being the largest group of health workers, have an important role in promotion of cervical cancer screening. To determine nurses' awareness of cervical cancer and their own screening practices at a hospital in Tanzania. A descriptive cross sectional study using questionnaires on 137 nurses. Data analysis was made by descriptive statistics and chi square tests. Less than half of the nurses had adequate knowledge regarding cervical cancer. There was a significant association between knowledge levels of causes of cervical cancer and transmission of HPV and age. Knowledge was more adequate among the young nurses (p = 0.027) and knowledge differed significantly between cadres. Registered nurses had more adequate knowledge than enrolled nurses (p = 0.006). The majority did not know screening intervals and a few were aware of HPV vaccine. Most nurses (84.6%) had never had a Pap smear examination. These results reflect a need for continuing medical education, creation of cervical cancer prevention policies and strategies at all levels of the health sector.

Molecular mechanisms of viral infection and propagation: An overview of the second Advanced Summer School in Africa

Molecular mechanisms of viral infection and propagation: An overview of the second Advanced Summer School in Africa

Prophylaxis of cervical cancer and related cervical disease: a review of the cost-effectiveness of vaccination against oncogenic HPV types.

Vaccines have demonstrated cost-effectiveness in managed care through the prevention of disease. As new vaccines for previously untargeted conditions are developed, pharmacoeconomic modeling is becoming even more critical for the quantification of value in the health care industry. Two recently developed vaccines aimed at prevention of infection from human papillomavirus (HPV) types 16 and 18 have proven to be highly efficacious. HPV 16 and 18 are the 2 most common oncogenic strains of HPV and are responsible for 70% of cervical cancer cases worldwide. Persistent infection with an oncogenic HPV type is a known cause of cervical cancer. Therefore, prevention of cervical cancer via HPV vaccination may have a significant financial impact. To qualitatively review existing mathematical models of the cost effectiveness of prophylactic HPV vaccination, with an emphasis on the impact on managed care in the United States. Mathematical models of the cost-effectiveness of HPV vaccination based on U.S. data were reviewed. A search of the PubMed database was conducted using the search terms "HPV," "vaccine," and "cost-effectiveness" for articles published before February 22, 2010. Studies employing mathematical models to estimate the cost-effectiveness of HPV vaccination in healthy subjects from the United States were included. Models based on data or populations from outside of the United States were excluded. Outcomes were measured with incremental cost-effectiveness ratios (ICERs), typically in units of quality-adjusted life expectancy (quality-adjusted life years [QALYs] gained). Most studies included in this review modeled vaccination of a cohort or population of females aged 12 years. Assessment of catch-up vaccination in females (through aged 24 to 26 years) was included in a couple of reports. One study examined vaccination in older females (aged 35, 40, and 45 years). Models typically compared a strategy of HPV vaccination with the current practice of cervical screening (sampling of cervical cells for disease detection) alone. 11 studies of cost-effectiveness modeling of HPV vaccination were included in this review. A direct quantitative comparison of model results is challenging due to the utilization of different model types as well as differences in variables selected within the same model type. Each model produced a range of cost-effectiveness ratios, dependent on variables included in sensitivity analyses and model assumptions. Sensitivity analyses revealed the lowest ICER to be $997 per QALY gained and the highest ICER to be $12,749,000 per QALY gained. This enormous range highlights the need to clarify what model assumptions are being made. The 2 studies that included modeling of catch-up vaccination scenarios in females older than age 12 years also produced a wide range of ICERs. One study, assuming 90% efficacy, 100% coverage, and lifelong immunity, modeled catch-up vaccination in all females aged 12 to 24 years and yielded an ICER of $4,666 per QALY. If the duration of protection was limited to 10 years, then costs increased to $21,121 per QALY. The other study modeling catch-up HPV vaccination assumed 100% efficacy, 75% coverage, and lifelong immunity. ICERs in this study for outcomes relating to cervical cancer ranged from $43,600 per QALY in the base model vaccinating only 12 year olds with no catch-up vaccination, to $152,700 in a model including catch-up vaccination through age 26 years. Although catch-up to age 21 years resulted in a cost of $120,400 per QALY, the ICER decreased to $101,300 per QALY if model outcomes related to prevention of genital warts were also included. The lone study modeling vaccination in women aged 35 to 45 years resulted in an ICER range of $116,950 to $272,350 per QALY when compared with annual and biennial cytological screening. Cost-effectiveness was defined as an ICER at or below $100,000 per QALY gained. All models of female adolescent vaccination were able to produce vaccination strategies that would be cost-effective according to this definition in addition to many strategies that would be cost-prohibitive. Variables influential in determining cost-effectiveness of HPV vaccination included the frequency of accompanying cervical screening, the age at which screening is initiated, vaccination efficacy, duration of vaccine protection, and the age range of females to be vaccinated. The actual effectiveness of HPV vaccination in the female population will also depend on levels of vaccine uptake or coverage and compliance in completing all vaccine doses. Clinical studies have shown HPV vaccination to be highly efficacious and potentially lifesaving if administered to females naive or unexposed to vaccine HPV types. Modeling studies have also shown that HPV vaccination can be cost-effective with an ICER of $100,000 or less per QALY gained if administered to females aged 12 years in the context of cervical screening intervals typically greater than 1 year. Catch-up vaccination through 21 years of age increases the cost per QALY to more than $100,000. Until real-world coverage rates increase, cost-effectiveness modeling of HPV vaccination underestimates the actual cost per QALY.

Major Changes in ACOG Cervical Cytology Screening Recommendations

The American College of Obstetricians and Gynecologists (ACOG) recently recommended important changes in cervical cytology screening practices.

Cervical Screening Awareness and Practice among Medical Personnel

ABSTRACT Objective The objective of this study was to assess awareness about cervical screening among medical and paramedical personnel. Design This was a cross-sectional study. Place and duration The study was conducted by Gyne unit-II, Jinnah Hospital/ AIMC Lahore, over a period of one month. Material and methods Three hundred and thirty personnel were interviewed. Out of them 243 were doctors and 87 were nurses. Each subject was asked to fill up a proforma designed to assess the knowledge about screening, source of information, associated risk factors, e.g age at first coitus, vaginal discharge, vulvo-vaginal warts, postcoital bleeding and/ or family history of cervical malignancy. Reasons for not doing cervical smear and future plans for screening were also evaluated. Results The majority of doctors (241 = 99%) had good knowledge about cervical screening, while only 53 nurses (60.9%) had some information mainly through discussion with doctors. Despite good knowledge only 27 doctors (11.0%) and 5 nurses (5.7%) underwent screening. Nearly 77% of all subjects intended to have future screening provided facility is easily accessible. Conclusion Our group included medical and paramedical staff who are definitely more educated than general public regarding importance of cervical screening, yet results revealed only 9.9% compliance rate among both doctors and nurses. There is intense need for mass media campaign for public awareness and clinical workshops for medical personnel.

Cost-effectiveness of quadrivalent human papillomavirus (HPV) vaccination in Mexico: A transmission dynamic model-based evaluation

We examined the potential health outcomes and cost-effectiveness of quadrivalent human papillomavirus (HPV) 6/11/16/18 vaccination strategies in the Mexican population using a multi-HPV type dynamic transmission model. Assuming similar cervical screening practices, with or without vaccination, we examined the incremental cost-effectiveness of vaccination strategies for 12 year-old females, with or without male vaccination, and temporary age 12-24 catch-up vaccination for females or both sexes. The most effective strategy therein was vaccination of 12-year-olds, plus a temporary 12-24-year-old catch-up program covering both sexes; whereby HPV 6/11/16/18-related cervical cancer, high-grade cervical precancer, and genital wart incidence was reduced by 84-98% during year 50 following vaccine introduction. Incremental cost-effectiveness ratios in the primary analyses ranged from approximately 3000 dollars (U.S.) per quality-adjusted life year (QALY) gained for female vaccination strategies to approximately 16000 dollars /QALY for adding male vaccination with catch-up.

Knowledge, attitude and practice of pap smear cervical screening among antenatal patients at Jos University Teaching Hospital, Jos, Nigeria

Knowledge, attitude and practice of pap smear cervical screening among antenatal patients at Jos University Teaching Hospital, Jos, Nigeria

The future of cytology laboratories

This presentation will consider the impact of established and potential changes to cervical screening practice on the structure and organisation of cervical cytology laboratories in the UK. Although full roll out of liquid based cytology in England will not be achieved until 2008, implementation of liquid‐based cytology (LBC) combined with the change in the screening age range and frequency has already resulted in a decrease in the total number of tests examined despite an increased number of women aged 25–64 being screened, reflecting a more efficient screening programme with fewer unnecessary tests outside the recommended screening age range [1]. Laboratories in England and Scotland have reported a decreased workload and increased productivity and efficiency, with no adverse effect on quality [2–4]. There is a growing mismatch between screening workload and capacity, with the potential to achieve laboratory reconfiguration within a managed network, as recommended in the Carter report [5]. However the potential for conflict between the Carter report recommendations and the autonomy of NHS foundation trusts will need to be addressed if laboratory reconfiguration is to be achieved.LBC provides the platform for automation of the screening process and human papillomavirus (HPV) and other evolving molecular testing. The MAVARIC trial due to report in 2010 will inform the decision about the adoption or otherwise of automation in the NHS Cervical Screening Programme (NHSCSP). In previous studies the systems currently under evaluation (Focal Point™ GS and ThinPrep® Imager) have been shown to increase productivity with no loss of sensitivity or specificity [6,7]. The adoption of automation in cervical screening will be a further driver for laboratory reconfiguration by amalgamation of workloads and an extended working day to achieve cost‐effective utilization of the equipment. It may also call into question the role of the cytology screener as currently utilized in the UK cervical screening programmes.Whilst the results of the ARTISTIC and TOMBOLA trials are awaited, sentinel sites have been established to evaluate the practical implications of introducing HPV testing for triage of low‐grade cytological abnormalities and follow up after treatment of CIN. A recent study from the USA suggests that the adoption of primary HPV testing in conjunction with cytology screening in women aged 30 years and older would result in a 30% reduction in the number of cervical screening tests performed [8]. It is likely that if HPV testing is adopted there will be a further reduction in laboratory workload, and as such HPV testing will be another driver for laboratory reconfiguration.Similarly, a modelling study from the UK predicted that HPV 16/18 vaccination of a cohort of 12‐year‐old girls would result over the lifetime of the cohort in a 23% reduction in the number of abnormal cytology tests [9], assuming that vaccine protection lasted for life and the introduction of vaccination did not also allow a reduction in screening frequency [10]. Furthermore, falling lesion prevalence is likely to decrease both the sensitivity and specificity of screening cytology tests and may be a driver for automation or the adoption of primary screening by HPV testing with secondary cytology triage [10].In summary, LBC implementation and change in the screening age range and frequency has been an initial driver to laboratory reconfiguration, in accordance with political objectives. In the longer term, this may be accelerated by automation, HPV testing and HPV vaccination and will also demand a revision of laboratory staffing levels and skill mix. Potential models of laboratory configuration and staffing will be outlined. However, whether all the developments described above are affordable, measured against manual test evaluation estimated to prevent up to 4500 deaths per annum in England at an annual cost of about £160 million remains to be determined [11].

Histopathology and Cytopathology of Cervical Cancer

Histopathology and cytopathology form the scientific and clinical basis for current prevention and treatment of cervical cancer. Histopathology determines treatment of cancer and precancer through classifying into a diagnosis the patterns of microscopic organization of cells in tissue sections from biopsy or surgical specimens. Although morphological concepts of cervical cancer and precancer evolution are giving way to viral and molecular knowledge, histopathology also remains important as the most widely used clinical endpoints by which the performance of new techniques for cervical cancer prevention are currently evaluated. Cervical cytopathology studies exfoliated cells taken from the surface of the cervix and is the main method of cervical screening in successful cervical cancer prevention programmes. These techniques have contributed hugely to reducing the burden of cervical cancer. Countries with successful implementation of cytological screening have shown a reduction in incidence and mortality by 70% or more [1,2]. These figures are historical comparisons and may underestimate the impact as they do not take account of observed increased rates in young women for whom screening provides little protection, and the impact of increasing exposure to oncogenic HPV and other risk factors in some countries as a consequence of major behavioural changes. On this basis, in the UK, the national programme started in 1988 has been estimated to prevent 4,500–6,000 deaths per year, with a very marked decline in [3] rates in women aged 30–34 y. Despite this, because of the difficulties and costs of this approach, globally, there are almost half a million cases of cervical cancer each year. Concurrently with the enormous success of cytological screening, there has been increasing knowledge of the challenges of the limited reproducibility of the diagnoses, of the complex relationships between cytological and histological diagnosis and the natural history of cervical precancer, particularly the driving role of infection with genital human papillomavirus (HPV). This review focuses on the concepts and terminology used in classifying morphological changes of cervical precancer and HPV infection, how this links to natural history through information from cervical screening and more recent cohort studies of HPV infection. It addresses the issues around the performance characteristics (reproducibility and accuracy) of cytopathology and histopathology as diagnostic tests, and the implications for cervical screening practice. Finally it discusses the use of cytopathology and histopathology as reference standards and endpoints in clinical research and biomarker development.

Raising Awareness and Providing Free Screening Improves Cervical Cancer Screening Among Economically Disadvantaged Lebanese/Armenian Women

Women need to practice cervical screening regularly to reduce morbidity and mortality. The purpose of this study was to examine the impact of an intervention program on knowledge, attitude, and practice of cervical screening in the population of Lebanese/Armenian women. The design was a cross-sectional, quasi-experimental posttest survey following a year long intervention program. The sample included 176 women, who were members of the Armenian Relief Cross in Lebanon. Interventions consisted of educational classes, media messages, and free screening. The instrument was a self-administered questionnaire. Knowledge of women with intervention was higher (p > .05) and practice rate increased between intervention and comparison groups. No difference in attitude was noted. The study was successful in raising awareness and increasing screening in the sample. It is recommended to continue helping women to overcome barriers for cervical screening.