Rates Of Invasive Cervical Cancer Research Articles

Comparative analysis of invasive cervical cancer incidence rates in three Appalachian states

Background. Invasive cervical cancer (ICC) rates remain elevated in the Appalachian region of the United States. We investigated patterns of invasive cervical cancer incidence rates in three Appalachian states (Kentucky, West Virginia, Pennsylvania) to uncover specific high-risk subgroups within this large and heterogeneous region. Methods. The analysis was conducted for the three states combined and individually. Invasive cervical cancer rates were characterized by individual and county-level sociodemographic variables, including age, race, poverty, education, Appalachian status, and rural/urban status. Bivariate analyses and multivariable Poisson regression models were conducted to address the relative contributions of each variable to the risk of invasive cervical cancer. Results. The three states differed in the contribution of each factor to the risk of invasive cervical cancer. The overall invasive cervical cancer incidence rates for Kentucky, West Virginia, and Pennsylvania were 13.4, 13.9, and 10.2 per 100,000/yr, respectively. After controlling for other demographic variables, the effect of Appalachian status on invasive cervical cancer was weaker, while rural status, education, and race were stronger, significant predictors. Conclusions. This study illustrates the heterogeneity of population demographics and invasive cervical cancer risk, and the need to identify subregions and subgroups within Appalachia at highest risk for this disease.

Comparative analysis of characteristics of women with cervical cancer in high- versus low-incidence regions

Objective. To identify particular characteristics that might help explain the markedly higher rate of invasive cervical cancer in southern China as compared with Australia. Methods. One hundred eighty-five women with cervical cancer were recruited between 1999 and 2001: 106 from Guangzhou and Changsha (southern China), and 79 from Sydney (southeast Australia). Demographic and risk factor information was obtained by questionnaire; clinicopathologic data were extracted from hospital records. The human papillomavirus (HPV) status of cancer biopsies was ascertained by consensus PCR assays, direct sequencing and/or Amplicor™ hybridisation. Results. The mean age of the Chinese was significantly lower than the Australians (44 versus 53 years), although mean age at first sexual intercourse was similar. Australian women were more likely to smoke, to report multiple sexual partners and to have a history of sexually transmitted diseases (but not of genital warts). However, they were better educated, were more frequent users of barrier contraception and were far more likely to report regular Pap smears before diagnosis. The HPV positivity rate of Chinese cancers (83%) was less than Australian tumours (90%); but HPV 16 and 18 were the most common genotypes in both populations (59% and 77%), and predominated in cancers from younger women. HPV types 58 or 59 were amplified from 12 (14%) of the Chinese but from only one Australian cancer. Conclusions. Cervical cancer is not only more common in China but also develops at a younger age than in Australia. While significant differences in some risk factors were observed, the much lower participation in cervical screening in southern China is likely to be of greatest consequence.

The Dutch CISOE-A framework for cytology reporting increases efficacy of screening upon standardisation since 1996

Aim: To describe the effect of introducing the CISOE-A framework for reporting cervical cytology results, including changes in repeat and referral advice in the Netherlands, on the efficacy of the...

Risk of invasive cervical cancer after three consecutive negative Pap smears.

To determine the factors that influence risk of cervical cancer after three consecutive negative Pap smears. A cohort study was conducted using data from the British Columbia Cervical Cancer Screening Program and British Columbia Cancer Registry. Analysis was based on a one percent sample of women aged 20-69 years with Pap smears enriched with all invasive cervical cancer cases diagnosed between 1994-99. Screening intervals, after three negative screens, were created with the following variables: age at beginning of interval, interval length, previous cytologic abnormality and previous cervical procedure. The risk of cervical cancer by histologic type was calculated using survival analysis methods. The sample consisted of 10,509 women, who contributed 28,309 intervals, and 371 cervical cancer cases. The incidence rate of invasive squamous cervical cancer increased with time since last screen up to six years. Women with a history of dysplasia remained at elevated risk for squamous cancer, hazard ratio=2.6 (95% confidence interval [CI]=1.9, 3.4) but age or previous procedure were not related to risk. No relationship between time since last screen and non-squamous cancer risk was found although history of a previous procedure was significant. The marginal effectiveness of Pap smears declined with increasing frequency of use. This study confirmed the preventive effect of Pap smear screening and its dependency on frequency of use. Women with a history of dysplasia, prior to three consecutive negatives, were at increased risk of developing invasive squamous cervical cancer compared with women with no such history.

Cervical cancer screening among Chinese Americans

Study purpose: Chinese women in North America have high rates of invasive cervical cancer and low levels of Papanicolaou (Pap) testing use. This study examined Pap testing barriers and facilitators among Chinese American women. Basic procedures: A community-based, in-person survey of Chinese women was conducted in Seattle, Washington during 1999. Four hundred and thirty-two women in the 20–79 years age-group were included in this analysis. The main outcome measures were a history of at least one previous Pap smear and Pap testing within the last 2 years. Main findings: Nineteen percent of the respondents had never received cervical cancer screening and 36% had not been screened in the previous 2 years. Eight characteristics were independently associated with a history of at least one Pap smear: being married, thinking Pap testing is necessary for sexually inactive women, lack of concerns about embarrassment or cancer being discovered, having received a physician or family recommendation, having obtained family planning services in North America, and having a regular provider. The following characteristics were independently associated with recent screening: thinking Pap testing is necessary for sexually inactive women, lack of concern about embarrassment, having received a physician recommendation, having obtained obstetric services in North America, and having a regular provider. Principal conclusions: Pap testing levels among the study respondents were well below the National Cancer Institute’s Year 2000 goals. The findings suggest that cervical cancer control interventions for Chinese are more likely to be effective if they are multifaceted.

Early withdrawal from cervical cancer screening: the question of cost-effectiveness

In countries such as the UK, mass population screening for cervical cancer has been undertaken since the 1960s. Although of established effectiveness, no formal evaluation of the screening protocol was carried out prior to its implementation. On the basis of a published mathematical modelling exercise, it has been speculated that withdrawing women from the screening programme at an earlier age than at present, whilst leading to a higher rate of invasive cervical cancer (ICC), could reduce resource use. Using estimates of screening and treatment costs, and of expected life-years lost following earlier withdrawal, we simulated cost-effectiveness ratios for various scenarios described by the model. Median cost savings resulting from a life-year lost never exceeded £10 000 for any scenario, although the estimates were particularly sensitive to the assumed age at cancer presentation and the rate of cancer progression. Our findings seem to offer little economic support for the early withdrawal of subjects from the cervical screening programme.

Design and results of the USA-Mexico border human papillomavirus (HPV), cervical dysplasia, and Chlamydia trachomatis study.

Mexico has one of the highest mortality rates of invasive cervical cancer in the world. This is particularly true for the states in northern Mexico that border on the United States of America. In addition, Hispanics in the United States have higher rates than do non-Hispanics in the country. Therefore, a binational team was formed to focus on this problem and to determine the risk factors and prevalence of cervical dysplasia and human papillomavirus (HPV) infection, the sexually transmitted disease (STD) known to cause cervical cancer. Chlamydia trachomatis infection, a common STD and potential HPV cofactor, was also assessed. Research was conducted in 1997 and 1998 in the border region of two states, Arizona in the United States and Sonora in Mexico, applying a cross-sectional study of women attending clinics for routine gynecologic care. Clinical measurements included Pap smears, HPV infection by both polymerase chain reaction (PCR) and Hybrid Capture (HC), and C. trachomatis status by HC and enzyme-linked immunoassay (EIA). A total of 2,436 women were enrolled (mean age 33.3 years +/- 10.3 years). The overall prevalence of abnormal cytology was 9.3%, with a significant difference in the prevalence in Mexico (11.4%) vs. the United States (6.6%). Of the participants, 14.5% of them tested positive for HPV by PCR, with no significant difference between the two countries, in spite of a lower behavioral risk profile for the Mexican women. Overall prevalence of C. trachomatis was found to be greater by HC than by EIA (8.2% vs. 3.0%), and in Mexico higher by both methods. An important accomplishment of the project was the implementation of a quality control program for Pap smear collection, which resulted in a significant reduction in inadequate smears in Mexico. Despite numerous potential logistical barriers, the binational team successfully conducted a large-scale study in the border area and developed an infrastructure for future research.

Cervical cancer screening among Chinese immigrants in Seattle, Washington.

Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants. We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration. Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated.

Epidemiology and biology of cervical cancer.

Worldwide, cancer of the cervix is the second leading cause of cancer death in women: each year, an estimated 500,000 cases are newly diagnosed. Among populations, there are large differences in incidence rates of invasive cervical cancer: these reflect the influence of environmental factors, screening Papanicolaou (Pap) tests, and treatment of pre-invasive lesions. The high-risk human papillomavirus (HPV) subtypes 16, 18, 31, 33, and 51 have been recovered from more than 95% of cervical cancers. We have made great strides in understanding the molecular mechanism of oncogenesis of this virus, focusing on the action of the E6 and E7 viral oncoproteins. These oncoproteins function by inactivating cell cycle regulators p53 and retinoblastoma (Rb), thus providing the initial event in progression to malignancy. Cervical cancers develop from precursor lesions, which are termed squamous intraepithelial lesions (SIL) and are graded as high or low, depending on the degree of disruption of epithelial differentiation. Viral production occurs in low-grade lesions and is restricted to basal cells. In carcinomas, viral DNA is found integrated into the host genome, but no viral production is seen. The well-defined pre-invasive stages, as well as the viral factors involved at the molecular level, make cervical carcinoma a good model for investigating immune therapeutic alternatives or adjuvants to standard treatments.

ABNORMAL PAPANICOLAOU SMEARS, GENITAL TRACT INFECTIONS, AND CONTRACEPTION

Cervical cancer ranks second among all cancers in women worldwide, and the rate of invasive cervical cancer among women under 50 is rising in the United States. Risk factors for abnormal Papanicolaou (Pap) smears and invasive cervical cancer include genital tract infections. This study was designed to compare the rates of genital tract infections and the contraceptive choices of a random sample of 800 women, using an ex post facto design. The Pap positive women had a significantly higher rate of genital tract infections than did the Pap negative women but did not differ significantly in use of contraceptive methods. Findings support those of other researchers suggesting genital tract infections as risk factors for abnormal Pap smears and are consistent with the literature in suggesting a role for oral contraceptive pills (OCPs) in acquisition of the human papillomavirus (HPV). Caregivers can help empower women to reduce their risks through informed choices about protection and sexual behaviors.

Trends in incidence of and mortality from invasive cancer of the uterine cervix in Scotland (1975–1994)

Objective: I. To identify major trends in the incidence of and mortality from invasive cancer of the cervix uteri in Scotland during the twenty year period 1975–1994; II. to consider the extent to which these trends may have been shaped by the introduction of systematic cervical screening. Design: Analysis of annual age standardised and age specific rates for incidence and mortality, based on data collected by the Scottish Cancer Registry and the General Register Office for Scotland. Setting: Scotland. Subjects: Women registered with the Scottish Cancer Registry as having developed invasive cancer of the cervix during the period of interest. Results: Annual all ages incidence rates of invasive cervical cancer show little overall change over the period 1975–1989, but exhibit a pronounced decline from 1990 onwards. All-ages mortality rates show clear evidence of decline during the period 1975–1994, the rate for 1994 being some 30% lower than that for 1975. Annual age-specific incidence rates show different patterns by age group, with clear evidence of decreasing trends in the age range 50–64 years but different patterns in younger and older age groups. Most age groups show steep declines in incidence from 1990 onwards. Age specific mortality rates for 1975–1994 exhibit the most pronounced decreasing trends in the age range 50–64 years. The trends identified are broadly similar to those experienced in England and Wales over an approximately comparable period. Conclusions: The overall (all ages) incidence of invasive cervical cancer in Scotland changed little during the period 1975–1989, but declined sharply from 1990 onwards. The most pronounced decline in incidence across the period 1975–1994 appears to have taken place in the age range 50–64 years. This decline has been accompanied by a commensurate fall in mortality in the same age range. These reductions in incidence and mortality may be attributable in part to increased coverage of cervical screening programmes during the period of interest. Evidence from other studies suggest that, without the increased coverage of cervical screening achieved during this period incidence rates in Scotland might have been seen to increase.

Peter Gardner's Review of the Society January 1989–September 1997

Objective: I. To identify major trends in the incidence of and mortality from invasive cancer of the cervix uteri in Scotland during the twenty year period 1975–1994; II. to consider the extent to which these trends may have been shaped by the introduction of systematic cervical screening. Design: Analysis of annual age standardised and age specific rates for incidence and mortality, based on data collected by the Scottish Cancer Registry and the General Register Office for Scotland. Setting: Scotland. Subjects: Women registered with the Scottish Cancer Registry as having developed invasive cancer of the cervix during the period of interest. Results: Annual all ages incidence rates of invasive cervical cancer show little overall change over the period 1975–1989, but exhibit a pronounced decline from 1990 onwards. All-ages mortality rates show clear evidence of decline during the period 1975–1994, the rate for 1994 being some 30% lower than that for 1975. Annual age-specific incidence rates show different patterns by age group, with clear evidence of decreasing trends in the age range 50–64 years but different patterns in younger and older age groups. Most age groups show steep declines in incidence from 1990 onwards. Age specific mortality rates for 1975–1994 exhibit the most pronounced decreasing trends in the age range 50–64 years. The trends identified are broadly similar to those experienced in England and Wales over an approximately comparable period. Conclusions: The overall (all ages) incidence of invasive cervical cancer in Scotland changed little during the period 1975–1989, but declined sharply from 1990 onwards. The most pronounced decline in incidence across the period 1975–1994 appears to have taken place in the age range 50–64 years. This decline has been accompanied by a commensurate fall in mortality in the same age range. These reductions in incidence and mortality may be attributable in part to increased coverage of cervical screening programmes during the period of interest. Evidence from other studies suggest that, without the increased coverage of cervical screening achieved during this period incidence rates in Scotland might have been seen to increase.

Design and methods of a population-based natural history study of cervical neoplasia in a rural province of Costa Rica: the Guanacaste Project.

This paper reports on the enrollment phase of a population-based natural history study of cervical neoplasia in Guanacaste, a rural province of Costa Rica with consistently high rates of invasive cervical cancer. The main goals of the study are to investigate the role of human papillomavirus (HPV) infection and its co-factors in the etiology of high-grade cervical neoplasia, and to evaluate new cervical cancer screening technologies. To begin, a random sample of censal segments was selected and enumeration of all resident women 18 years of age and over was conducted with the aid of outreach workers of the Costa Rican Ministry of Health. Of the 10738 women who were eligible to participate, 10049 (93.6%) were interviewed after giving written informed consent. After the interview on cervical cancer risk factors was administered, a pelvic examination was performed on those women who reported previous sexual activity. The pelvic examination included a vaginal pH determination and collection of cervical cells for cytologic diagnosis using three different techniques. Additional cervical cells were collected for determination of the presence and amount of DNA from 16 different types of HPV, and two photographic images of the cervix were taken and interpreted offsite by an expert colposcopist. Finally, blood samples were collected for immunologic and micronutrient assays. Women with any abnormal cytologic diagnosis or a positive Cervigram, as well as a sample of the whole group, were referred for colposcopy, and biopsies were taken when lesions were observed. The enrollment screening will serve as the basis for a prevalent case-control study, and the members of the cohort free from serious disease will be followed actively, at intervals of no more than a year, to study the natural history of HPV infection and the origins of high-grade squamous intraepithelial lesions (HSIL). Details of the field operation are outlined, with particular reference to the realization of this kind of study in developing countries. Descriptive data on the prevalence of disease and exposure to various risk factors are also presented.

International incidence rates of invasive cervical cancer before cytological screening.

Huge differences in incidence rates of invasive cervical cancer occur among populations. These differences reflect the influences of both etiological environmental factors and removal of precursor lesions detected upon screening. The purposes of this article are (i) to describe similarities and differences in the shapes and magnitudes of age-specific incidence rates of invasive cervical cancer before screening had an effect, (ii) to provide baseline data for further global study of screening effects, and (iii) to provide baseline incidence data for the design of optimal screening programs. To eliminate the impact of screening effects, we have selected age-specific incidence rates from times when and from populations in which screening was insignificant. The selected rates were suitably scaled and compared regarding age at onset of increase in incidence, age at peak incidence, and rate of subsequent decline. Despite a 16-fold difference in incidence rates, all curves had the same basic structure, with an increase to a peak followed by a decline or a plateau. Although all populations but one had an onset around age 25, 7 European countries showed an earlier peak age (mean = 46 vs. 59) and a more rapid decline after the peak than most other populations. The common basic shape of the age-specific incidence curve, overall, suggests a relatively similar development of invasive cervical cancer in different populations. These results illustrate the underlying similarities in the markedly different age-specific incidence rates of invasive cervical cancer. They also provide a basis for studying screening effects and for optimizing screening programs in specific geographic areas.

International incidence rates of invasive cervical cancer after introduction of cytological screening.

Because Pap-smear screening can detect pre-invasive cervical cancer, such screening can markedly reduce the occurrence of invasive cancer. However, its impact in different populations is uncertain. This study compares the changes in cervical cancer incidence at different ages after the introduction of screening in different populations, and addresses the impact of organized and opportunistic smear taking. We identified 17 cancer registries large enough and existing long enough to analyze screening effects. For each registry, we calculated the relative reduction in age-specific incidence rates and in incidence rates age-standardized to the world population after the introduction of cytologic screening. In 11 of the 17 populations, age-standardized incidence rates declined markedly from 27 percent in Norway and to 77 percent in Finland. Age-specific declines were confined to women aged 30 to 70 years old with a nadir around ages 40 to 55. In six other populations, age-standardized incidence rates declined less than 25 percent, an amount too small to provide unambiguous evidence of a screening effect. In several populations, cytologic screening had a more pronounced effect than is generally recognized. Because age-specific declines in cervical cancer incidence rates were strikingly similar in populations with widely different screening practices, organized screening may not be markedly superior to opportunistic screening. The reduction in reported cancer incidence because of screening is smaller in younger and older women.

Decreasing rates of cervical cancer among American Indians and Hispanics in New Mexico (United States).

Minority women in New Mexico (United States)--including American Indian and Hispanic women--have shown disproportionately high incidence rates of invasive cervical cancer during the 1960s and 1970s. Several public health programs in New Mexico were directed toward early detection of cervical cellular abnormalities, particularly targeting the state's minority women. To evaluate the effectiveness of these programs, we examined the New Mexico Surveillance, Epidemiology, and End Results (SEER) data collected from 1969-92, and calculated average annual, age-specific, and age-adjusted incidence rates by ethnic group (American Indian, Hispanic, and non-Hispanic White) for five-year time intervals. We also calculated age-adjusted mortality rates for cervical cancer in the same ethnic groups using state vital records. Age-adjusted incidence rates for invasive cervical cancer show substantial temporal decreases, especially for minority women in the state. The age-adjusted incidence rate decreased by 66 percent, from 30.3 to 10.3 per 100,000 for American Indian women, and by 61 percent, from 26.1 to 10.2 per 100,000 for Hispanic women. A stage shift to earlier stages of cervical neoplasia occurred over the study period, with a substantially higher proportion of in situ compared with invasive cancers diagnosed in the most recent cf the most remote time period. The ratio of incidence rates of in situ to invasive cancers changed dramatically for both American Indian and Hispanic women. Cervical cancer mortality rates decreased steadily among Hispanic women from 1958 to 1992; the decrease among American Indian women was less stable and fluctuated due to small numbers. Ongoing targeted screening programs should help to reduce cervical cancer incidence and mortality further in New Mexico.

Cancer incidence of Hispanics and non-Hispanic whites in Cook County, Illinois.

Variations in cancer incidence and mortality rates between Hispanics and non-Hispanic whites have been reported in several regions in the United States. This report describes the ethnic variation in selected cancer sites in Cook County, Illinois. Cancer incidence, age-specific, and age-standardized relative rates, and 95% confidence intervals were estimated among Hispanics and non-Hispanic whites in Cook County, Illinois, for 1986-1987. Hispanics were identified using surnames and maiden names with the Generally Useful Ethnic Search System (GUESS). Rates of lung cancer in Hispanics were approximately half of those observed for non-Hispanic whites. Hispanics also had lower rates of colon, breast, and bladder cancer. Hispanic females had rates of invasive cervical cancer that were approximately two times higher than those of non-Hispanic whites. These results are consistent with previous studies and suggest that Hispanics residing in the United States may retain some of the risk profile of those living in their home country.

Towards achieving the Health of the nation target for cervical cancer: accuracy of cancer registration

To measure the accuracy of incidence rates for invasive cervical cancer derived from cancer registration data, a review of histopathology records was undertaken for all cases of invasive cervical cancer, a 20 per cent random sample of CIN 3 registrations and all cases of cancer of the uterus not otherwise specified (NOS) from Greater Manchester, which were registered by the North Western Regional Cancer Registry between 1988 and 1989. The subjects were 386 cases of invasive cervical cancer, 313 CIN 3 registrations and 69 cases of cancer of the uterus NOS. The main outcome measure was the incidence rate of invasive cervical cancer in Greater Manchester after adjusting for errors in cancer registration. It was found that 375 (97 per cent) of the 386 cases of invasive cervical cancer were verified against the original pathology report but 11 cases (3 per cent) had been registered as invasive cervical cancer in error. Nine cases of invasive cervical cancer were found to have been misclassified as CIN 3, and 10 cases as cancer of the uterus NOS. As the CIN 3 cases were a 20 per cent random sample of all CIN 3 registrations, the best estimate of the number of cases of invasive cervical cancer misclassified as CIN 3 is 45, which makes a total under-registration of 55 cases over the two-year period. After adjusting for under-and over-registration, the incidence rate of invasive cancer of the cervix in Greater Manchester for 1988-1989 increased from 16.5 to 18.1 per 100,000 population.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimating cervical cancer incidence in the Hispanic population of Connecticut by use of surnames.

The problem of estimating cancer incidence in the growing population of Hispanic women in the Northeastern United States has received little attention. Age-specific incidence rates (1980-1988) for invasive and in situ cervical cancer for Hispanic women were estimated by matching individual surnames in the population-based Connecticut Tumor Registry with the 1980 census list of Spanish surnames. Maiden names, obtained from death records of women previously receiving diagnoses of invasive cervical cancer, also were matched with the Spanish-surname list. Estimated age-specific invasive cervical cancer rates for Hispanic women, based on matching individual surnames in the registry with the Spanish-surname list, were higher than rates for all white women in all age groups and at least as high as those for all black women in most age groups. Comparison of maiden names with individual surnames for deceased women, however, suggested that use of individual surnames resulted in some misclassification of Hispanic ethnicity. The findings indicated that the estimation of cancer rates for Hispanic women in Connecticut could be improved by obtaining maiden names of all women receiving cancer diagnoses.

Incidence of dysplasia and carcinoma of the uterine cervix in an Appalachian population.

Cervical cancer mortality rates in the Appalachian population of southeastern Kentucky have been shown to be unusually high. To better understand the high cervical cancer death rate in this area, we developed a population-based cervical disease registry. This study describes the incidence of cervical dysplasia, carcinoma in situ, and invasive cervical cancer in 1986 and 1987 among White women in a 36-county area of Appalachian Kentucky based on histologic diagnoses. We compared average annual age-adjusted incidence rates for carcinoma in situ and invasive cervical cancer in the study area with those for women in the Surveillance, Epidemiology, and End Results (SEER) Program. The incidence rate of invasive cervical cancer for women in the study area (14.9 per 100,000) was nearly twice that for White women in the SEER population (7.8 per 100,000), but it was similar to that for Black women in the SEER population (15.3 per 100,000). The incidence of carcinoma in situ for women in the study population (38.2 per 100,000) was 21% higher than that for White women (31.5 per 100,000) or for Black women (31.2 per 100,000) in the SEER population. The average annual age-adjusted incidence rate for all grades of dysplasia among women in the study population was 194.6 per 100,000. No comparable population-based incidence rates for dysplasia could be identified. Cervical cancer incidence rates are higher in Appalachian Kentucky than in the SEER population. Poverty appears to be a factor associated with these rates. Low-density populations such as those in rural Appalachia deserve greater attention in cancer control research. The population-based cervical dysplasia rates reported here may be useful for comparisons in future investigations.