The Road Ahead for Cervical Cancer Prevention and Control

Abstract

Since the early 1950s, Papanicolaou (“Pap”) cytology screening has dramatically reduced cervical cancer mortality in most high-income settings. Currently, human papillomavirus (hpv) vaccination has the greatest potential to reduce the global burden of cervical cancer and precancerous lesions. However, as the prevalence of precancerous lesions declines, maintaining cytology as the primary screening test in settings with established programs might become less efficient. A reduction in test performance (sensitivity, specificity, and positive predictive value) would lead to an increase in unnecessary colposcopy referrals. Fortunately, hpv dna testing has emerged as a suitable candidate to replace cytology. Compared with the Pap test, hpv testing is less specific but much more sensitive in detecting high-grade precancerous lesions, less prone to human error, and more reproducible across settings. Linkage of hpv vaccination and screening registries could serve the added role of monitoring vaccine efficacy. As a triage test, cytology is expected to perform with sufficient accuracy because most hpv-positive smears would contain relevant abnormalities. This approach and others—for example, hpv testing followed by genotyping—are being evaluated in large population studies and have already been recommended in some settings. Other specific biomarkers that might perform well for screening and triage include hpv E6/ E7 messenger rna testing, methylation of host or viral genes, and p16INK4a staining. Considering the rapid pace of major discoveries and the anticipated arrival of a nonavalent hpv vaccine (currently in phase iii trials), the evidence base in this field has become an elusive target and will continue to be an obstacle for policymakers.

Examen de detección de virus papiloma humano en el tamizaje de cáncer cervicouterino en un Servicio de Salud de Santiago, Chile

“…Se ha sugerido que reservar la citología para este grupo reducido de mujeres con mayor riesgo, permitiría mejorar su calidad 13 . Otras opciones de estratificación están actualmente siendo evaluadas en varios países y en nuestro medio, tales como la genotipificación de los VPH 16 y 18, el uso de métodos visuales y varios marcadores moleculares de integración viral o de avance de las alteraciones celulares causadas por el VPH 16 . Aunque no fue parte de los objetivos del estudio la medición del impacto psicosocial que genera en las mujeres un resultado VPH positivo, esto ha sido demostrado en otros estudios 17,18 .…”

The significantly lower risk of cervical cancer at and after the recommended age to begin and end screening compared to breast and colorectal cancer

“…The importance of developing risk thresholds for cervical cancer screening is especially significant given the introduction and increased uptake of HPV vaccines, which are predicted to reduce cervical cancer by 70-90% (Munoz et al, 2003;Kjaer et al, 2009;Kirby, 2015). This marked decrease in cervical cancer in the coming decades will necessitate considerable changes to screening practices (Gillison et al, 2008;Tota et al, 2010Tota et al, , 2014. Indeed, during the latest updates to guidelines the issue of whether the age to begin screening in the U.S. should be delayed for vaccinated women was raised.…”

Uterus kanser insidansı ve mortalitesi, ve dünyada İnsani Gelişme İndeksi ile ilişkisi

“…Therefore, the incidence of cervical cancer is lowest in countries in which screening programs for women are available 25 . In some parts of the world, the screening program is insufficiently available.…”

“…Its incidence follows a substantially different pattern in different geographical areas, and this needs to be explained. Since the introduction and widespread use of prevention programs, particularly the Papanicolaou (Pap) smear, vaccination against the Human Papillomavirus (HPV), and early treatment, the incidence and mortality of cervical cancer has steadily and significantly declined in developed countries 25 .…”