Survey of Cervical Cytology in General Practice

In a practice in an industrial area a cervical cytology service was offered to women, and in the years 1967-70 280 cervical smears were carried out. In 1971 all women born between 1 January 1920 and 31 December 1935 who had not had a cervical smear taken in the preceding four years were sent a letter explaining the service and inviting them to attend. Those who did not attend received a second letter and, if necessary, a visit by a nurse in an effort to persuade them to do so.Eventually 88·4% of the women in this age group who could be traced attended, and 16 abnormal cervical smears were reported. As a result of cone biopsy 12 women were found to have carcinoma in situ.     

A pilot study of cervical screening in an inner city area—lessons for a national programme

The objectives of this study were to examine aspects of organization of a proposed national screening programme based in general practice. The target population of women aged 25–59 years and their general practitioners (GPs), in a defined inner city area, was identified from a population register of persons eligible for free medical services; a computerized system was developed for invitations and record linkage of cytology results. Smears were examined in one laboratory and follow up of women with abnormal smears was undertaken by one gynaecologist. A random sample of non‐responders was surveyed by questionnaire. Response following two invitations was only 20%. Practices with male doctors only had significantly lower reponse rates ( P <0.001) than those with a female doctor/nurse. A survey of non‐responders showed that over 20% of addresses were incorrect and 16% of those interviewed were ineligible for smear tests. A preference for a female to undertake smears was expressed by 67%, and 77% believed that the purpose of the cervical smear was to detect cancer. An accurate population register, health promotion, support for GP practices, provision of alternative venues for smear tests, development of computer systems, accurate data entry and fail‐safe follow up are aspects of a cervical screening service which must be addressed prior to setting up a national service.     

Quinquennial cervical smears: every woman's right and every general practitioner's responsibility.

Out of 558 women aged 16 to 64 who were registered with one general practitioner, 459 were eligible to be screened for cervical cancer. Even though the practice had been taking cervical smears for many years, they were predominantly from women under 35. Of the eligible women between 35 and 64, 111 (37%) had never had a smear. After short term intensive screening the uptake rates, defined by a smear done within the past five years, rose to 100% for women under 35, 94% for those aged 35 to 64, and 96% for all eligible women. Screening was rewarding both in its clinical yield and in the income generated by item of service payment. The success of screening was largely due to the participation of practice nurses in taking smears, and to a new method of recording smear results and claims for them. Some women, however, refused to have cervical smears.     

Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project.

OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject''s home. Recording of preventive information was ascertained from general practitioners'' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners'' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.     

Follow up of women with a history of mildly abnormal cervical smears which have returned to normal without treatment

The progress of 124 women with at least two negative cervical smears following a history of mildly abnormal smears for which no treatment had been given was compared with 106 women with negative smears and a clinical history of genital warts or herpes virus infection and 460 age-matched controls. After 4 years, excluding those for whom there was no follow up, 5.8% of those with a history of abnormal smears, none of those with a clinical history of genital warts or herpes virus and 1.1% of controls had developed histological evidence of at least cervical intraepithelial neoplasia grade III (CINIII) when referred for investigation of subsequent abnormal smears; one woman, from the control group, had developed invasive cervical cancer. Women with two negative smears after a history of abnormal smears who subsequently developed CINIII were more likely to have had a previous smear reported as moderate or mild-moderate dyskaryosis (2/6) compared with those whose follow up was negative (2/89). the results suggest that two negative cervical smears may not necessarily indicate that a lesion has regressed, but that a clinical history of genital warts or herpes virus infection should not be an indication for increased surveillance.     

Long term follow up of women with borderline cervical smear test results: effects of age and viral infection on progression to high grade dyskaryosis.

OBJECTIVE--To follow up and assess the significance of borderline change in cervical smears. DESIGN--Retrospective study of women undergoing routine cervical cytological screening in 1981. SETTING--Avon Cervical Screening Programme, covering 250,000 women in Bristol and Weston super Mare. SUBJECTS--437 women showing borderline cervical changes in 1981 and 437 age matched controls with normal results in 1981. MAIN OUTCOME MEASURES--Cytological progression to high grade dyskaryosis (cervical intraepithelial neoplasia grade III or invasive carcinoma). RESULTS--During follow up ranging from 13 to 106 months 98 of the 437 women (22.4%) with borderline cytological changes on routine cervical cytology screening had a subsequent smear test showing high grade dyskaryosis compared with three of the 437 women (0.9%) in the control group. The risk of progression was greater in women aged 20 to 39 than in those aged 40 and over. Human papillomavirus infection had initially been diagnosed cytologically in 101 of the 437 (23%) women with borderline results. Significantly fewer of these women developed high grade dyskaryosis (13/98 (13%) v 88/339 (26%), p less than 0.05). CONCLUSIONS--Women with borderline smear test results are at increased risk of developing high grade dyskaryosis, particularly if the borderline changes occur without cytological features of human papillomavirus infection. Progression occurs within three years in 50% of cases, although a linearly increasing risk was sustained over the nine years of follow up and was greatest in women aged 20 to 39. Careful follow up of these women is indicated.     

Cervical screening in Perth and Kinross since introduction of the new contract.

OBJECTIVE--To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. DESIGN--Analysis of computerised records of cervical screening both before and after introduction of the new contract. SETTING--General practices in Perth and Kinross Unit, Tayside. PATIENTS--A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. MAIN OUTCOME MEASURES--Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. RESULTS--Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. CONCLUSION--The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.     

Screening for cervical cancer: a new scope for general practitioners? Results of the first year of colposcopy in general practice.

A survey was carried out over one year of all the women who attended a colposcopy clinic in a general practice. During the year 1254 women underwent cytological screening in the practice and 197 of these underwent colposcopy. Of 79 women with abnormal smears that suggested cervical intraepithelial neoplasia, 62 (79%) were confirmed by biopsy to have cervical premalignancy. In addition, the remaining 118 women with normal or inflammatory smears underwent colposcopy either because of their history or because they requested the investigation. A general underestimate of cervical intraepithelial neoplasia when cytology alone was used was discovered. Seven out of 28 women with inflammatory smears were found to have important cervical premalignancy. Mildly dyskaryotic smears led to a falsely reassuring estimate of the degree of severity of cervical lesions. Seven out of 13 patients who underwent colposcopy because they were thought to be at high risk of neoplasia because of a history of genital warts, unexplained recurrent cystitis, heroin abuse, or immunosuppression had cervical intraepithelial neoplasia proved at biopsy. This report shows that both in screening for and in the follow up of known cervical disease a normal smear cannot guarantee normal pathology. Diagnostic colposcopy is a valuable complementary investigation that could be carried out in a general practice.     

Using patient and general practice characteristics to explain variations in cervical smear uptake rates.

OBJECTIVES--To produce practice and patient variables for general practices from census and family health services authority data, and to determine the importance of these variables in explaining variation in cervical smear uptake rates between practices. DESIGN--Population based study examining variations in cervical smear uptake rates among 126 general practices using routine data. SETTING--Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London. MAIN OUTCOME MEASURE--Percentage of women aged 25-64 years registered with a general practitioner who had undergone a cervical smear test during the five and a half years preceding 31 March 1992. RESULTS--Cervical smear uptake rates varied from 16.5% to 94.1%. The estimated percentage of practice population from ethnic minority groups correlated negatively with uptake rates (r = -0.42), as did variables associated with social deprivation such as overcrowding (r = -0.42), not owning a car (r = -0.41), and unemployment (r = -0.40). Percentage of practice population under 5 years of age correlated positively with uptake rate (r = 0.42). Rates were higher in practices with a female partner than in those without (66.6% v 49.1%; difference 17.5% (95% confidence interval 10.5% to 24.5%)), and in computerised than in non-computerised practices (64.5% v 50.5%; 14.0% (6.4% to 21.6%)). Rates were higher in larger practices. In a stepwise multiple regression model that explained 52% of variation, five factors were significant predictors of uptake rates: presence of a female partner; children under 5; overcrowding; number of women aged 35-44 as percentage of all women aged 25-64; change of address in past year. CONCLUSIONS--Over half of variation in cervical smear uptake rates can be explained by patient and practice variables derived from census and family health services authority data; these variables may have a role in explaining variations in performance of general practices and in producing adjusted measures of practice performance. Practices with a female partner had substantially higher uptake rates.     

Urinary incontinence: prevalence,need for treatment,and effectiveness of intervention by nurse.

OBJECTIVE--To measure the unmet need of patients with regular urinary incontinence (incontinence twice or more a month) treatable by a nurse. DESIGN--Self completed postal questionnaire and randomised controlled trial of assessment and intervention by a nurse. SETTING--One urban and one rural general practice in Somerset. SUBJECTS--7300 adults randomly selected from 10,300 aged 35 and over on the combined practice lists. 515 women and 185 men with regular incontinence were offered assessment and treatment, of whom 134 women and 49 men had no intervention for three months (historical controls). They then joined the assessment and treatment programme. INTERVENTION--Four sessions of pelvic floor exercises and bladder retraining supervised by non-specialist nurse who had taken a three week course on assessing and treating uncomplicated incontinence. MAIN OUTCOME MEASURES--Number of patients desiring treatment; self reported cure, improvement, or deterioration in continence after three months. RESULTS--The questionnaire achieved a 79% response. Validated responses showed a prevalence of 4.4% in men and 16.4% in women aged 35-64. 315 (45%) of the 700 patients offered assessment refused it and seven had moved away or died, 64 men and 41 women were referred to their general practitioner. 197 of 292 treated women (68%) reported cure or improvement compared with seven (5%) of controls. 22 of the 86 men desiring treatment were suitable for intervention by the nurse. Seventeen were cured or improved compared with none of the men in the control group. CONCLUSIONS--About half the people with regular urinary incontinence took up the offer of treatment (9.2% of women and 3.4% of men in the study population). This condition can be effectively managed by a nurse with limited training.     

How predictive is a cervical smear suggesting glandular neoplasia?

The prevalence of endocervical adenocarcinoma and its precursors has increased, in part due to increased diagnostic awareness of these lesions. To date, limited information has been published regarding the predictive value of glandular abnormalities in cervical smears. This study details the histological follow up of 418 cervical smears showing glandular abnormality, reported in our department over a six year period from 1993 to 1998. Histological follow up was available for 395 of the 418 smears (94.50%). The overall positive predictive value (PPV) for this group of smears was 72.66% for either significant glandular or squamous pathology (at least low grade cervical glandular intraepithelial neoplasia or CIN2 on follow up biopsy), and 55.70% for significant glandular pathology alone. Examination of subcategories of abnormal glandular smear showed that the PPV increased with the degree of abnormality reported within the smears.     

Cervical cancers diagnosed after negative results on cervical cytology: perspective in the 1980s.

OBJECTIVES--To assess the magnitude of the problem of interval cancers of the cervix (those that are diagnosed within a short time after negative screening test results) in the 1980s, to compare the nature of interval cancers in younger women with that in older women, and, by reviewing negative cervical smears, to determine the proportion of interval cancers that might represent the development of malignancy anew compared with the proportion that might be associated with difficulties in sampling or errors in reporting. DESIGN--An audit of the interval cases of cervical cancer that had been diagnosed within 36 months of a smear having been reported as negative by the Victorian Cytology Gynaecological Service among women registered with cervical cancer during 1982-6. SETTING--The Victorian Cytology Gynaecological Service, a free public sector cytology laboratory in Victoria, Australia. SUBJECTS--138 Women, all of whom had had cervical cancer diagnosed during the 36 months after having had a negative cervical smear. Subjects were divided into two age groups: younger women, aged less than 35; older women, aged 35-69. INTERVENTIONS--Negative slides were reviewed for evidence of optimal sampling and for the presence of cellular abnormalities that had been missed at the time of the original reporting. MAIN OUTCOME MEASURES--The number of interval cases of cancer of the cervix registered during 1982-6. The proportion of interval cases occurring in younger women and the proportion occurring in older women. Division of women into three risk categories based on clinical history and screening history that broadly corresponded to the probability that a diagnosis of cervical cancer might be expected during the 36 months after the issuing of a negative smear report. RESULTS--138 Of 1044 (13.2%) women who had been registered with cervical cancer during 1982-6 had had one or more negative smears during the 36 months preceding the diagnosis of cancer. Interval cancers comprised a larger proportion of registrations of cervical cancer in women aged less than 35 years than in women aged 35-69 (21.1% v 11.0%, p less than 0.01). Women with interval cancer who had had at least three negative smears during the 10 years before the diagnosis of cancer were commoner in the younger age group than in the older age group (7.0% v 2.5%, p less than 0.01). When, however, the number of observed cases of squamous cell carcinoma was related to the number of expected cases in the absence of screening, no significant difference was found between the two age groups (6.8% v 4.8%, p greater than 0.10). The rate of diagnosis of interval cancer per 100,000 negative tests was lower among younger women than among older women (10/100,000 v 16/100,000). Review of the negative slides showed that 11.9% were again considered to be negative with an optimal sample having been obtained as evidenced by the presence of endocervical cells or metaplastic cells, or both. CONCLUSIONS--Interval cancers might comprise a larger proportion of all registered cases of cervical cancer among younger women owing to the larger proportion of such cancers being prevented in this age group. Among women with interval cancer review of the negative slides showed that most were accounted for by suboptimal sampling or by errors of reporting.     

Are patients with abnormal cervical smears adequately managed?

The outcome was assessed for all 1062 women in Nottingham who had a first report of abnormal cervical cytology in 1981. Satisfactory follow up could be found for only 628 (59%) of them. For 275 (26%) one subsequent normal smear had been reported but no further follow up requested. For 43 (4%), no subsequent test, after the abnormal smear, had been requested by the patient''s general practitioner. Thirty patients (3%), 22 of whom had been tested at a special clinic, had not responded to a request for follow up. Even after extensive efforts we could not find the outcome in the remaining 86 (8%) of the patients. Adequate follow up of patients with abnormal cervical cytology is not being achieved. Improvements in the records systems and some changes in procedure should be made to reduce this problem.     

Investigation of non-responders at a cervical cancer screening clinic in Manchester

Uptake of cervical cytology screening in a Manchester practice has been very low (14%) in spite of the family practitioner committee introducing a call and recall system. A questionnaire was used to investigate the attitudes of non-responders, who were all from social classes IV and V. Attendance was found to be inhibited by a high level of anxiety about the test and about cervical cancer, by erroneous beliefs, and by concurrent family difficulties. More than half the non-attendance was directly attributable to administrative errors, which resulted in appointments being sent to wrong addresses or to inappropriate people (four after hysterectomy, 10 who had had recent smears). These matters require urgent attention.Several simple measures might improve attendance at clinics, follow up of patients, and attitudes toward screening: invitations to attend the clinic, a register of patients and results, a simpler version of the leaflet, use of well known personalities to promote cervical screening, health education campaigns, and regular evaluation of records.     

Adherence to recommendations for early repeat cervical smear tests.

OBJECTIVE--To assess adherence to recommendations for an early repeat cervical smear test in women with reports of cytological abnormalities, and to evaluate the impact of reminder letters to medical practitioners when such smear tests are overdue. DESIGN--Observational study. SETTING--Cytology (gynaecological) service for Victoria, Australia. SUBJECTS--Two groups of women who had abnormal cervical smears during 1985. Women in group A had some evidence of an important dysplasia and were advised to have a repeat smear in three months'' time whereas women in group B had a less serious abnormality and were advised to have a repeat smear test in six months'' time. In all, 971 of the 1036 women in group A and 1401 of the 1464 women in group B were eligible to have a repeat smear analysed by the service. INTERVENTION--If a repeat smear had not been received within three months of the recommended date a reminder letter generated by the service''s computer was sent to the medical practitioner who had taken the smear. END POINT--Thirty six months after the report on the abnormal smear was issued. MEASUREMENTS AND MAIN RESULTS--In all, 870 (90%) of the women in group A and 1154 (82%) of the women in group B had a repeat smear test. The mean time to a repeat test was 3.0 months (95% confidence interval 0.5 to 16.4) in group A and 6.0 months (1.2 to 30.3) in group B. The reminder letter to the practitioner potentially increased the rate of return for a repeat smear test by 18% in group A and 24% in group B. Adherence to the recommendation for a repeat test increased with increasing age. CONCLUSIONS--Achieving high rates of follow up smear tests and appropriate management in women with cytological abnormalities is critical to the impact of a screening programme for cervical cancer. The reminder system used in this study was not labour intensive or expensive and provided a fail safe mechanism for ensuring that reports of abnormal smears were not overlooked.     

Loop diathermy excision of the cervical transformation zone in patients with abnormal cervical smears.

OBJECTIVE--To determine the efficacy and morbidity of fine loop diathermy excision of the cervical transformation zone as applied to the management of outpatients with abnormal cervical smears. DESIGN--Prospective programme trial with six month follow up. SETTING--Two hospital based colposcopy clinics. PATIENTS--616 Patients aged 16-60 with abnormal cervical smears. INTERVENTIONS--After colposcopic and cytological assessment excision of the cervical transformation zone by fine loop diathermy under local anaesthesia in the outpatient department. MAIN OUTCOME MEASURES--Time to complete the treatment, immediate morbidity in terms of discomfort and bleeding, and cytological and colposcopic findings at six months. RESULTS--Treatment was completed in a mean of 3.47 minutes (SD 1.99). Immediate morbidity was minimal, and histological specimens were adequate in over 90% of cases. Almost two thirds of patients were treated at their first visit to the clinic. 58 Patients (9.4%) failed to attend for follow up at six months and one had had a hysterectomy. Of the 557 patients who attended for colposcopic and cytological follow up at six months, 506 (91%) were normal cytologically and 19 (3.4%) had histologically confirmed persistence of cervical intraepithelial neoplasia. The overall confirmed failure rate of the technique was 4.4%. CONCLUSION--Loop diathermy excision is an effective treatment with low morbidity and is an appropriate modality for patients with abnormal cervical smears.     

Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia

A. Repše‐Fokter, A. Pogačnik, V. Snoj, M. Primic‐Žakelj and M. S. Fležar
Review of negative and low‐grade cervical smears in women with invasive cervical cancer after the first 3 years of the national cervical screening programme in Slovenia Objective: The purpose of the study was to perform a national review of negative, low‐grade and inadequate smears reported during the latest screening period before cervical cancer diagnosis in 2006, after the first 3 years of the screening programme. Methods: Among 162 new cervical cancer cases there were 47 (29%) without previous cytology, 47 (29%) with one high‐grade smear prior to diagnosis and 68 (42.0%) with at least one previous negative, low‐grade, atypical or inadequate smear 1–40 months before diagnosis. Of the latter 68 cases, 37 patients with 59 smears (together with 118 control slides) were included in the review as 31 had smears reported at laboratories no longer operating. Findings were related to the last cytology report before diagnosis as well as to histological type and stage of the cancer. Results: In our study group, 19 (51%) of 37 patients had squamous cell carcinoma, 15 (41%) adenocarcinoma and 3 (8%) adenosquamous carcinoma, compared with 121 (75%), 26 (16%), 12 (7%), respectively, and 3 (2%) other types, for all carcinomas. Twenty‐one of 37 women also had high‐grade cytology prior to diagnosis of cancer. Women with previous cytology (with or without recent high‐grade smears) were more likely to have stage I cancers than those without cytology (P < 0.0001). The expert group upgraded 17/33 smears in the patients with squamous carcinomas, which was more than in those with adeno‐ and adenosquamous carcinomas (5/24, P < 0.05). Conclusion: As expected, a higher proportion of smears preceding adenocarcinomas were true negative. Under‐diagnosed smears were not related to cancer stage or last cytology report before diagnosis.     

Outcome analysis of 4 years' follow-up of patients referred for colposcopy with one smear showing mild dyskaryosis

Objective: To assess the 4‐year outcome of patients after one smear showing mild dyskaryosis with respect to smear regression rate, prevalence of cervical intraepithelial neoplasia (CIN) and the effect of age. Methods: Retrospective analysis of patients diagnosed with initial mildly dyskaryotic smear during the year 2000 with a follow‐up period of 48 months. These women had not had any previous abnormal smears. Settings: Cytopathology Department and Colposcopy Unit, King’s College Hospital, London, UK. Results: We identified 524 patients of whom 375 patients with complete follow‐up data are included. The age range was 19–67 years with a median of 29 years. There were 207 patients aged 35 years or less (55%). At 6 months, 258 smears were performed and 47.8% of them were negative (95% CI: 41.6–54.0%). The total number of negative follow‐up smears in the first year was 198 out of a total of 397 smears performed (50%). This proportion has significantly increased between 1 and 4 years’ follow‐up to 67.5% (RR: 1.24; 95% CI: 1.14–1.35). Over the 4‐year period, 791 smears were performed and 477 were negative (60.3%; 95% CI: 56.9–63.7%). Of the 477 negative smears there were only 61 smears (12.8%; 95% CI: 10–16%), in 54 patients (14%; 95% CI: 11–18%) that reverted back to low‐grade cytological abnormality. In only one case the repeat smear showed high‐grade abnormality after initial negative follow‐up; however, on biopsy, histology showed CIN I. Out of the 375 patients, 70 required treatment with excisional biopsy (19%; 95% CI: 15.0–22.9%). Histology confirmed high‐grade CIN in only 41 cases giving a prevalence of 11% (95% CI: 8.1–14.5%). There were no cases of microinvasive or invasive cancer detected. Age (≤35 years versus >35 years) did not significantly affect either cytological or histological outcome. Conclusion: Sixty per cent of follow‐up smears after initial mild dyskaryosis subsequently became negative; of them 87.2% remained negative over the 4 year follow‐up. Treatment was only required in 19% of patients, with 11% prevalence of high‐grade CIN. Age did not affect the outcome. These results are reassuring and indicate that colposcopic referral may not be necessary after only one mildly dyskaryotic smear.     

Cervical cancer screening: A Slovenian experience

In Slovenia, opportunistic screening was introduced in regular gynaecological practice in 1960. The proportion of population screened was unknown, as well as there were no standards for quality assurance and control. Despite great number of smears read, there were no major changes in invasive cervical cancer incidence in the period 1979 till 1993, but in 1994 the incidence rate started to increase again to reach its peak in 1997 (23,1/100.000, 241 new cases). Based on the experiences from the countries with effectively organised screening programmes, a decision was made in 1996 by the Minister of Health to nominate a group of experts to prepare a proposal for organised cervical cancer screening programme after testing the methodology in pilot study. In the pilot the central computerised information system (Screening Registry) was gradually established to register all smears from the whole country, to identify women who do not attend for screening to send them invitation for screening and to monitor screening activity and its quality. The aim of pilot was also to develop guidelines for quality assurance and control of all procedures involved in cervical cancer screening and treatment of intraepithelial lesions. In three years since the beginning of the national programme, nearly 70% of women in the target age group were registered with at least one smear. All other results are presented in regular programme reports. There is still place for further development of the programme, but the incidence of cervical cancer already started to decline especially among younger women, who attend for screening more often than those aged over 50.