The objective of cervical cancer screening is to reduce cervical cancer incidence and mortality by detecting and treating precancerous lesions. Conventional cytology is the most widely used cervical cancer screening test. Although cytology has been effective in reducing the incidence of and mortality from cervical cancer in developed countries in both opportunistic and--more dramatically--organized national programs, it has been less successful and largely ineffective in reducing disease burden in low-resource settings where it has been implemented. Liquid-based cytology, testing for infection with oncogenic types of human papillomaviruses, visual inspection with 3-5% acetic acid, magnified visual inspection with acetic acid, and visual inspection with Lugol's iodine have been evaluated as alternative tests. Their test characteristics, and the applications and limitations in screening, are discussed with an emphasis on the work of the Alliance for Cervical Cancer Prevention over the past 5 years.
Cervical cancer is an important public health problem in many developing countries, where cytology screening has been ineffective. We compared four tests to identify the most appropriate for screening in countries with limited resources. Nineteen midwives screened 5,435 women with visual inspection (VIA) and collected cervical samples for HPV testing, liquid-based cytology (LBC) and conventional cytology (CC). If VIA was positive, a doctor performed magnified VIA. CC was read locally, LBC was read in Lima and HPV testing was done in London. Women with a positive screening test were offered colposcopy or cryotherapy (with biopsy). Inadequacy rates were 5% and 11% for LBC and CC respectively, and less than 0.1% for VIA and HPV. One thousand eight hundred eightyone women (84% of 2,236) accepted colposcopy/cryotherapy: 79 had carcinoma in situ or cancer (CIS1), 27 had severe-and 42 moderate-dysplasia on histology. We estimated a further 6.5 cases of CIS1 in women without a biopsy. Sensitivity for CIS1 (specificity for less than moderate dysplasia) was 41.2% (76.7%) for VIA, 95.8% (89.3%) for HPV, 80.3% (83.7%) for LBC, and 42.5% (98.7%) for CC. Sensitivities for moderate dysplasia or worse were better for VIA (54.9%) and less favourable for HPV and cytology. In this setting, VIA and CC missed the majority of high-grade disease. Overall, HPV testing performed best. VIA gives immediate results, but will require investment in regular training and supervision. Further work is needed to determine whether screened-positive women should all be treated or triaged with a more specific test. ' 2007 Wiley-Liss, Inc.Key words: Pap smear; hybrid capture; low-resource settings; clinical trial; screening Cervical cancer is the commonest female cancer, a major cause of death and an important public health problem in many developing countries. 1 Screening by routine cytology, using Papanicolaou stain (Pap), has had a major impact on cervical cancer rates in many developed countries, but not in any developing country despite its widespread use. 2-4 A number of other cervical screening tests have been proposed. Here, we wanted to identify the most appropriate test for use in developing countries with high rates of cervical cancer and limited resources.In Peru, as in most Latin American countries, cervical cancer is usually detected in an advanced incurable stage, despite widespread use of cytology screening. 5,6 Others have documented numerous problems of screening in Peru. Samples may be poorly collected, slides may be incorrectly labelled and some never reach the laboratory. Cytology results are sometimes wrongly transcribed or are not reported. 6 Cytology laboratories suffer from deficient infrastructure, inadequate training and supervision, staff shortages, lack of followup procedures and lack of internal and external quality control leading to suboptimal reading of cytology for which considerable expertise is required. This study was set up to investigate a variety of screening tests that may be more effective in such a setting.L...
As recently as two decades ago breast cancer was not a significant public health concern in Latin America and the Caribbean (LAC). However, mortality rates from breast cancer have been increasing for at least 40 years in most LAC countries. Socioeconomic development and consequent changes in reproductive behaviors over the past 50 years are thought to have contributed to the increased risk of breast cancer. Socioeconomic development has also increased women's health awareness and therefore the demand for quality services. In industrialized countries, screening and widely available, high-quality treatment protocols are being implemented as the main strategy for breast cancer control. Studies show that out of three available screening methods (mammography, clinical breast examination, and breast self-examination), only mammography for women 50-69 years of age has been effective at reducing mortality, and has done so by an estimated 23%. While there is much controversy about the benefits and cost-effectiveness of mammography screening for women aged 40-49, some countries, including Australia, the United States of America, and four European nations, recommend that physicians assess the need for it on an individual basis. A survey that we conducted of LAC countries shows that most of their breast cancer screening policies are not justified by available scientific evidence. Moreover, as seen by relatively high mortality/incidence ratios, breast cancer cases are not being adequately managed in many LAC countries. Before further developing screening programs, these countries need to evaluate the feasibility of designing and implementing appropriate treatment guidelines and providing wide access to diagnostic and treatment services. Given the relevance of breast cancer in Latin America and the Caribbean today, it is crucial that both women and health care providers have access to up-to-date information on which to base their decisions.
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