Cervical screening in Luxembourg: 1990–1999

For quality assurance purposes, the results of the 1990's obtained by the National Cervical Cancer Screening Programme (NCCSP) launched in 1962 were reviewed. The positive cytodiagnosis, the histologically verified in situ and invasive cervical cancers and the mortality rates were reported.     

Involving the General Practitioner In Screening For Cervical Cancer

In the Leiden region, the cervical cancer screening programme for the age group 35–54 years shifted in 1989 from one in which the smears were taken by specially trained paramedical personnel in health centres to a programme where the general practitioner is the smear taker. Hence, it is possible to compare the results of the two types of screening to evaluate whether involvement of general practitioners leads to better uptake of screening. In the 6 year period evaluated in this paper, the 3-yearly cytological rate per thousand for severe dysplasia or worse increased from 1.00 to 3.40; when stratified by age the positive rates were significantly higher. the histological rate per thousand for severe dysplasia increased from 0.60 to 2.09, and for carcinoma in situ from 0.35 to 1.36. All six invasive carcinomata were detected in the GP programme (0.31%). the general practitioner is clearly more able to attract the ‘high-risk’groups. Dans la reéion de Leiden, le programme de dépistage du cancer du col pour les tranches d'âge de 35–54 ans a été modifié en 1989. Le programme était initialement basé sur des frottis faits dans des centres de santé, par un personnel paramédical ayant suivi une formation particulière. Après 1989, le médecin généraliste est devenu le préleveur. II est done possible de comparer les résultats de ces 2 types de dépistage et d'apprécier si la participation des médecins généralistes a pour conséquence un meilleur dépistage. Au cours de la période d'étude, les taux pour 1000 de positivité cytologique pour les lésions graves (de type dysplasie sévère et plus) et par période de 3 ans ont augmenté de 1,00 à 3,40. Lorsque l'on stratifie sur l'âge, les taux de cas positifs sont significativement supérieurs. Le taux histologique des dysplasies sévères pour 1000 passe de 0,60 à 2,09 et celui du carcinome in situ de 0,35 à 1,36. Les 6 cas de carcinome invasif ont été détectés par le programme impliquant les médecins généralistes (0,31%). II est clair que le médecin généraliste est mieux placé pour dépister les patientes à“haut risque”. Im Bezirk von Leiden wurden die Abstriche der 35- bis 54 jährigen vor 1989 von speziell ausgebildeten Hilfskräften in Gesundheitszentren hergestellt, während diese Aufgabe dann von den Allgemeinmedizinern übernommen wurde. Dies erlaubt einen Vergleich zwische den Präparaten von zwei jeweils 3 Jahre umfassenden Perioden. Der Anteil schwerer Dysplasien und stärkerer Veränderungen nahm von 1.00 auf 3.40 pro Tausend zu. Der histologische Anteil der schweren Dysplasien erhöhte sich von 0.60 auf 2.09 und der der Carcinomata in situ von 0.35 auf 1.36. Alle 6 nachgewiesenen invasiven Carcinome wurden in den Abstrichen der Allgemeinmediziner entdeckt (0.31%_o). Damit ist klar, daß die Allgemeinmediziner die Risikogruppen besser zu erfassen vermögen.     

Preliminary results of a district call scheme for cervical screening organised in general practice.

A recognised problem with the cervical screening programme in the United Kingdom is the failure to include women who have never had a cervical smear test, who are a high risk group. The implementation of a district based call scheme in East Berkshire in 1986 is described whereby women aged 20-64 with no record of a cervical smear test who were judged to be eligible for testing by their general practitioner were sent a personal invitation from their general practitioner to attend for a test. A list of high risk unscreened women was kept by each practice, and a duplicate sent to the cytology laboratory to update the central records. Six months after each batch of invitations had been sent the resulting number of women having a smear test was assessed. Forty three of 51 practices approached agreed to participate in the five year scheme. During the first year lists were sent to the 43 participating practices. The first list was returned to the cytology laboratory by 37 practices and the second by 33; practices varied in their responses, however, some needing considerable persuasion to return the lists. Of 972 identified unscreened women from the total 3757 women listed in the lists of the family practitioner committee, 247 (25%) had a cervical smear test in response to the invitation, representing an overall increase of 7% in the screened population. The preliminary findings of the five year study have shown that screening can be improved by a systematic call scheme. Coordinated support from the area health authority in health education, monitoring of screening, and feedback of data from the scheme to practices is required to reduce the proportion of unscreened women.     

Some Aspects of Cervical Screening In Southern New Zealand; the Situation Before Implementation of the National Cervical Cancer Prevention Programme

To gain some idea of cervical screening in Otago and Southland (two southern provinces of New Zealand), before the implementation of a national cervical cancer prevention programme, a questionnaire was sent to all doctors identified as smear takers. Questionnaires were returned by 75% of the doctors. Only 53.8% of practice nurses were involved in taking smears. Well Women Clinics staffed by nurses were not widespread in either province. Just under half (46.4%) of doctors took cervical smears as part of a health check programme. Sixty-three per cent (63.3%) routinely performed a pelvic examination when taking a smear. Surprisingly few doctors were familiar with the technique of placing spatula and cytobrush samples on one slide, a manoeuvre which could significantly reduce the workload of the cytology laboratories. Only a minority of doctors were aware of a new sampler which can provide samples equivalent to combined spatular-cytobrush smears. There was confusion over the timing of a repeat smear following two normal ones. the recommended interval of 3 years was only complied with by 44.2% of doctors. However, 71.4% of respondents did remind women to have smears. the study indicates that many doctors already provide patients with a good cervical screening service, and this augers well for the national screening programme. Afin d'abtenir des informations sur le dépistage du cancer du col utérin dans les provinces d'Otago et de Southland (2 provinces du sud de la Nouvelle Zélande), préalablement au lancement d'un programme de prévention, un questionnaire a été envoyéà tous les médecins susceptibles de réaliser des frottis. Ces questionnaires ont été renvoyés par 75% d'entre eux. Seulement 53.8% des infirmiéres sont concernées par la réalisation des frottis. Les ‘Well Women Clinics’dirigées par des infirmiéres ne sont pas très répandues dans ces deux provinces. Moins de la moitié des médecins (46.4%) font des frottis dans le cadre d'un programme de bilan de santé. Soixante trois pourcent (63.3%) font un examen pelvien systématique lorsqu'ils réalisent un frottis. De façon surprenante, peu de médecins sont familiarisés avec la technique de l'étalement sur une même lame de la spatule et de la cytobrush, technique qui réduit notable-ment le travail des laboratoires de cytologie. eule une minorité de médecins est au courant de l'existence de ce nouveau système permettant d'obtenir l'equivalent d'un frottis combinéà la spatule et à la cytobrush. Une confusion a été constatée à propos de l'intervalle recommandé après 2 frottis normaux. Les médecins se sont conformés à l'intervalle recommandé de 3 ans pour 44.2% d'entre eux. Cependant 71.4% des médecins répondeurs rappellent à leurs patientes qu'elles doivent faire pratiquer des frottis. Cette étude montre que de nombreux médecins proposent une bonne utilisation du dépistage du cancer du col à leurs patientes, signe de bonne augure pour le programme national de dépistage. Um die Lage hinsichtlich eines gynäkologischen Screenings in den beiden südlichen Provinzen von Neuseeland, Otago und Southland, zu erfassen, wurden Fragebogen an alle Ärzte verschickt von welchen bekannt wer, daß sie Abstriche herstellen. 75% der Fragebogen wurden beantwortet. Nur in 53.8% der Praxen waren die Schwestern mit der Herstellung der Abstriche betraut. In beiden Provinzen gab es kaum ‘Well Women Clinics’. Etwas weniger als die Hälfte (46.4%) der Ärzte fertigen Cervikalabstrich im Rahmen eines Gesundheitscheques an, 63% (63.3%) von diesen führte routinemäßig gleichzeitig eine Beckenuntersuchung durch. Überraschenderweise waren nur wenige Ärzte mit der Technik Spatel-und Cytobrushmaterial auf einem einzigen Objektträger aufzutragen vertraut, nur eine Minderheit kannte neue Verfahren, die dem kombinierten Spatel- und Cytobrushabstrich entsprechen. Es herrschte Unklarheit hinsichtlich der Kontrollzeiträume nach 2 normalen Abstrichen. Der empfohlene Zeitraum von 3 Jahren war nur 44.2% der Ärzte bekannt. Trotzdem forderten 71.4% die Patientinnen auf, Abstriche herstellen zu lassen. Die Studie zeigt, daß viele Ärzte ihre Patientinnen bereits mit einem guten Screeningprogramm versorgen und bietet somit gute Voraussetzungen für ein nationales Screeningprogramm.     

Cervical screening in an inner city area: response to a call system in general practice.

To determine whether a cervical screening call system based in general practice in a deprived inner city area would increase the numbers of women who came forward for cervical smears the response to letters of invitation for screening was monitored for one year in one general practice in the Paddington and North Kensington district of London. Women aged 20-64 were identified from the computerised age-sex register. Only 16% of these women had had a smear test. A total of 750 call letters was sent out. Initially the response was poor (57 women; 22%), and 85 (32%) letters were returned marked "address unknown." After the age-sex register was updated the response to call was 330 women (44%). The response of women aged over 35 was better than the response of women aged 35 and under (229 (53%) v 101 (32%)). In the year of the study the number of women aged 20-64 on the revised register who had been screened rose by 330 (14%). A general practice based call system can improve uptake of cervical screening even in a highly mobile, socially underprivileged population.     

Costs and benefits of cervical screening. I. The costs of the cervical screening programme

In 1991, the average total Health Service cost of a cervical smear, including follow up at the colposcopy clinic, was almost £22.70 in the Perth and Kinross district of Scotland. The average cost per colposcopy clinic visit was £30. The main cost elements were in general practice (55% of total) and the laboratory (33%), and most of the cost was for staff time.     

Making sense of medically unexplained symptoms in general practice: a grounded theory study

Background General practitioners often encounter patients with medically unexplained symptoms. These patients share many common features, but there is little agreement about the best diagnostic framework for describing them.Aims This study aimed to explore how GPs make sense of medically unexplained symptoms.Design Semi-structured interviews were conducted with 24 GPs. Each participant was asked to describe a patient with medically unexplained symptoms and discuss their assessment and management.Setting The study was conducted among GPs from teaching practices across Australia.Methods Participants were selected by purposive sampling and all interviews were transcribed. Iterative analysis was undertaken using constructivist grounded theory methodology.Results GPs used a variety of frameworks to understand and manage patients with medically unexplained symptoms. They used different frameworks to reason, to help patients make sense of their suffering, and to communicate with other health professionals. GPs tried to avoid using stigmatising labels such as ‘borderline personality disorder’, which were seen to apply a ‘layer of dismissal’ to patients. They worried about missing serious physical disease, but managed the risk by deliberately attending to physical cues during some consultations, and focusing on coping with medically unexplained symptoms in others. They also used referrals to exclude serious disease, but were wary of triggering a harmful cycle of uncoordinated care.Conclusion GPs were aware of the ethical relevance of psychiatric diagnoses, and attempted to protect their patients from stigma. They crafted helpful explanatory narratives for patients that shaped their experience of suffering. Disease surveillance remained an important role for GPs who were managing medically unexplained symptoms.     

Cervical cytology screening: experience of a general hospital.

At Henderson General Hospital, Hamilton, a program was introduced whereby cervical smears were taken routinely for cytologic study from all women admitted aged 17 years or older. The procedure was performed by a specially trained nurse. In a 5-year period 53% of eligible patients were screened. Of these, 32% had not had a cervical smear taken before. In 7681 smears nine instances of invasive disease were discovered: three of the cervix, three of the endometrium and three metastatic. There were 20 cases of carcinoma in situ and 2 of severe dysplasia. Evidence of infection was present in a high percentage of the smears. Hospital admission affords an excellent opportunity of applying this valuable screening procedure.     

Cervical cancer screening in Mediterranean countries: implications for the future

K. Syrjänen, L. Di Bonito, L. Gonçalves, L. Murjal, M. Santamaria, V. Mahovlic, P. Karakitsos, B. Önal and F. C. Schmitt Cervical cancer screening in Mediterranean countries: implications for the future Prompted by feedback from the 34th European Congress of Cytology (ECC), the practice of including a special symposium in the programme was continued in the 35th ECC in Lisbon (2009) by arranging a satellite symposium entitled ‘Cervical Cancer Screening in the Mediterranean Countries’. Because of the importance to the future of this discipline, it was felt appropriate to summarize the highlights of this symposium here. Cervical cancer prevention strategies in the countries participating in the symposium (Portugal, Spain, Italy, Croatia, Greece and Turkey) appear to be highly variable. As yet, none of these countries can demonstrate a fully implemented national screening programme, but all are in different phases of designing and/or setting up such a programme, which is important. At present, the time‐honoured concept of cervical cancer prevention by Pap smear screening is under review, because prophylactic human papillomavirus (HPV) vaccines demonstrate a potential to prevent the vast majority (albeit not all) of cases of cervical cancer in the foreseeable future. Cervical cancer screening is still needed in this emerging era of HPV vaccination, but clearly the existing screening strategies must be modified to provide a cost‐effective combination of vaccination and screening. If the currently evaluated new screening strategies, such as HPV testing followed by cytology triage, become a reality, there is the likelihood that the Pap test will have only a secondary role, subordinate to HPV testing. Supporters of this scenario claim that Pap test performance will deteriorate in vaccinated populations. Reduced positive predictive value (PPV), due to lower disease prevalence, is inevitable, however, and this would also affect HPV tests. Any decline in sensitivity and specificity depends on human performance, and as such is avoidable by taking appropriate preventive measures. As clinical cytologists, we should focus attention on minimizing the risk to the Pap test of falling sensitivity because of unfamiliarity with abnormal cells, and also of reduced specificity if the fear of missing significant disease leads to overcalling of benign abnormalities.     

Cervical cancer: cytological cervical screening in Iceland and implications of HPV vaccines

K. Sigurdsson
Cervical cancer: cytological cervical screening in Iceland and implications of HPV vaccines This paper reviews the Icelandic experience regarding the age‐specific effectiveness, optimal targeted age range and intervals in cervical cancer screening and the screening implications of the HPV16/18 vaccines. The background material is based on data from a screening programme with centralized records dating back to 1964, as well as from population‐based studies on the distribution of oncogenic HPV types in cancer and histologically verified CIN2‐3 lesions and from the Icelandic arm of the Future II trial with Gardasil^®. The findings confirm significant increased rates in the screened population of CIN2‐3, stage IA (microinvasive) cancer since 1979, mainly in the age group 20–34 years. These lesions start to accumulate within 3 years of a normal smear. Studies on the distribution of HPV types indicate that the marketed vaccines could lower the incidence of cancer and CIN2‐3 by about 67% and 53%, respectively, after taking into account reported cross‐protection. About 65% of women below 25 years of age had lesions related to the non‐vaccine types and after the last normal smear these cases accumulated at the same frequency as cases with vaccine‐included types. Cases with combined vaccine and non‐vaccine types accumulated at a slower rate. We conclude that screening should continue to start at age 20 years, with invitations at 2‐year intervals up to age 39 years and thereafter at 4‐year intervals up to age 65–69 years. Current data support the conclusion that the optimal age for catch‐up HPV vaccination should be considered in the context of sexual practices and the data do not support changes in the lower age limit or screening intervals for the vaccinated women.     

Cervical screening in England and Wales: its effect has been underestimated

Opinions about cervical screening in the UK tend to follow one of two negative lines of thought. The first is that cervical cancer is a rare disease, and too much time and effort are spent on screening. The second is that it has been relatively ineffective, since incidence of invasive carcinoma did not fall until the NHS Cervical Screening Programme (NHSCSP) was introduced in 1988, although it fell by 40% since then. This paper presents publicly available data to demonstrate that neither of these views is true. Registrations of invasive carcinoma of the uterine cervix and carcinoma in situ in England and Wales between 1971 and 1996 show that a substantially increased risk of disease in women born since 1940 has been reversed, almost certainly by greatly improved screening. Cervical carcinoma is now a rare disease because most cases are prevented before they become invasive, mostly by screening young women, aged 20-40, before the decade of life when symptomatic cervical carcinoma most frequently presents.     

Rapid screening: a comparative study

Although rapid screening of negative and inadequate cervical smears is a quality assurance requirement for all UK laboratories, there has been little attempt to standardize the method and laboratories make use of a number of different techniques and times. The aim of this study was to assess the sensitivity of these various techniques by measuring their ability to pick out known false-negative smears. Completed questionnaires from 123 laboratories across England revealed that 52% of laboratories use a "step" technique, 19% use "turret", 15% use random paths and 34% attempt to rescreen the whole slide quickly. Twenty-two percent of laboratories use a mixture of techniques. Timings are also variable, with the majority of laboratories allowing screeners to review slides at a pace decided by themselves but usually between 1 and 2 min. The study involved 120 participants who performed a total of 24 000 rapid screens. The results showed that, of the 90 abnormal slides used in the study, 62 cases (69%) were identified as abnormal or needing review by more than 50% of participants. Overall rapid screening picked out 58% of high-grade squamous abnormalities, 59% of low-grade abnormalities and 72% of glandular lesions. Step screening performed best, followed by whole slide/random and then turret. One minute was the optimum time and there was a significant fall in performance once individuals attempted to rescreen large numbers (>50). The most significant finding was the marked variation in the performance of individuals using the same slide sets.     

Blood-pressure screening and supervision in general practice.

Since April 1975 all men aged 35-69 years registered with four general practices in west central Scotland have had their blood pressure checked whenever they visit the surgery. Although the practice locations range from rural to city centre and observers comprise receptionists, nurses, and doctors, a standard procedure has been adopted for the examination, recording, follow-up, and management of high blood pressure. The results confirm that raised blood pressure is common and often goes undetected. Even when hypertension is known, casual blood pressure readings often exceed accepted normal levels. The findings also show that a population may be routinely examined through normal contact with the family doctor, and that this can provide a convenient, acceptable, and effective means of detecting and reducing raised blood pressure.