Trends in cervical cancer incidence in the district of Florence

Cervical Cancer Epidemiology in Friuli Venezia Giulia

Aims and background

Until 1998 there was opportunistic screening in Friuli Venezia Giulia (FVG). Beginning in 1999, formal screening efforts were organized. The regional cancer registry was established in 1998, and data on incidence was collected for the period 1995–98. The scope of this study is to provide baseline data on the incidence of invasive cervical cancer in FVG for further examination of trends in incidence and of the effectiveness of screening efforts.

Methods

Data from the regional cancer registry database was examined and linked with data from the regional pap smear screening database.

Results

The incidence of cervical cancer in FVG was 8.6 per 100,000. Most women were diagnosed in stages I and II. Most cervical cancers (80%) were squamous cell. Opportunistic screening in FVG reached 39.8% of the total female population. Analysis by local health unit showed heterogeneous data.

Conclusions

FVG has one of the highest incidence rates of cervical cancer in italy. Approximately 1/3 of the diagnoses were in women over the age of 65. Pap smear screening prior to the formal program covered a low percentage of the female population. Screening efforts in the future should focus on screening coverage in the older female population.

Colposcopy as a Primary Screening test for Cervical Cancer

Aim and background

To evaluate the cost effectiveness of screening by colposcopy compared to conventional cytology.

Methods

A prospective study was performed in the Florence District screening center on 3,000 consecutive women, self referring, who were examined by cytology and colposcopy in a blind fashion. Further assessment was based on cytologic report or on colposcopy-directed punch biopsy. Actual costs of the whole screening process were known. The cost effectiveness of different possible simulated screening scenarios was then determined.

Results

Overall, 18 high-grade lesions (CIN3 = 9, CIN2 = 9) were detected. Four different screening scenarios were compared, namely a) cytology alone, b) cytology + repeat smear for ASCUS (atypical squamous cells of undeterminate significance) cases, c) colposcopy + cytology for cases of condyloma at punch biopsy, and d) colposcopy alone. Although they had a higher cost per examined woman (a) = 17.98, b) = 19.40, c) = 23.86, d)= 22.10 US$), scenarios c) and d) had a higher relative sensitivity (a = 44.4, b = 61.1, c = 100, d = 88.8%) and a lower cost per high-grade lesion detected (a = 6,743, b = 5,291, c = 3,977, d = 4,144 US$).

Conclusions

Screening by colposcopy is a feasible procedure which is more sensitive and more cost effective than conventional cytologic screening. At least in those settings where access to cytopathology may be difficult, screening by colposcopy should be considered as a possible alternative.

Follow-up after LLETZ: a study of 682 cases of CIN 2-CIN 3 in a single institution

OBJECTIVE

To evaluate the importance of resection margins in the risk of persistent/recurrent lesions and to investigate other factors such as detection of high-risk HPV, which could potentially predict persistent/recurrent disease before patients engage in follow-up.

STUDY DESIGN

682 women with a histologically confirmed diagnosis of CIN 2-3 treated by loop electrosurgical excision procedure (LEEP) were included, between January 2000 and December 2006. Age, high-risk HPV detection determined by Hybrid Capture II and cone margins were evaluated as possible predictors of persistent/recurrent disease.

RESULTS

The mean age at diagnosis was 37.8 years (range 18-73). The mean follow-up period was 39.9 months (SD 25.8). 6.6% of patients (45/682) were lost to follow-up. 64.7% of patients (441/682) had clear margins in the specimen and 20.1% of patients had positive surgical margins (137/682). In 8.6% of patients (59/682) the resection margins were uncertain. Positive endocervical sweep was found in 10.8% of cases (73/682). Residual/recurrent disease was demonstrated by colposcopy-guided biopsy in 13.9% of patients (88/637); 77.3% (68/88) of them developed CIN 1 while only 22.7% (20/88) developed high-grade premalignant lesions or carcinomas during the follow-up. We found significant differences in the frequency of persistent/recurrent disease depending on the status of margins: 24.8% of cases with positive margins vs 11.1% of cases with negative margins (p<0.0001). Multivariate analysis showed that only post-treatment high-risk HPV detection and status of the cone margins were significantly predictive of persistent/recurrent disease (OR 4.1, 95%CI 2.4-7.3, p<0.0001 and OR 2.7, 95%CI 1.5-4.7, p=0.001; respectively).

CONCLUSION

The combination of histological examination of resection margins plus post-treatment tests for HPV detection would help to classify LEEP-treated patients into categories at different risk of recurrence.

Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia

Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is approximately 2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage.

Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up

OBJECTIVE

To assess chances of adequate cyto-colposcopic follow-up after laser conization performed in postmenopausal screening population by the evaluation of postoperative cervical stenosis and unsatisfactory colposcopy rates.

PATIENTS AND METHODS

One thousand two hundred eighteen patients were submitted to laser CO2 conization for cervical intraepithelial neoplasia (CIN). Incidence and risk factors for cervical stenosis and unsatisfactory follow-up were retrospectively evaluated comparing fertile with postmenopausal patients.

RESULTS

Global incidences of postoperative unsatisfactory colposcopy and cervical stenosis were 46.2% and 7.1%. These rates were higher in postmenopausal patients compared with fertile ones, revealing a statistical correlation between unsatisfactory follow-up and postmenopausal status at the time of conization. Association between CIN relapse and cervical stenosis was significantly higher in postmenopausal group (66.7% vs. 8.6%; P <0.05), where two cases of recurrence were detected only after hysterectomy, because of an insurmountable cervical stenosis. Univariate and multivariate analysis revealed HRT use as the only significant factor in influencing postoperative cervical stenosis.

CONCLUSION

Conization is still considered as the standard treatment for CIN at any woman's age, when excisional management is indicated, but all postmenopausal patients should be counseled about the possibility of postoperative stenosis that could exclude an adequate follow-up, configuring a failure of the conservative treatment. HRT use is associated with a low risk of stenotic complications; therefore, if possible, users should be encouraged to continue therapy at least 1 year after laser conization.

Cervical cancer screening in Italy

Until recently cervical cancer screening in Italy has been mainly spontaneous, with only a few organised programmes. This resulted in low coverage and high frequency of tests in screened women (mostly every year). The situation is, however, rapidly changing. In 1996 nationwide organised programmes, on a regional basis, were recommended. National guidelines recommend personal invitation of women aged 25-64 years for a Pap-test every third year. At the end of 1999 34% of the Italian population 25-64 years old was included in organised programmes. Most organised programmes have fail-safe systems for women referred for colposcopy, protocols for diagnostic work-up and treatment and reference centres for such phases, according to the recommendations of national and European guidelines. However the size of laboratories is frequently smaller than recommended. Most organised programmes implement quality assurance processes for cytology interpretation, that have been intensive in some centre, but there is no nationwide standardisation. In recent years data for monitoring screening activity have been collected in a standardised way by most organised programmes, in the framework of GISCi (Italian Group for Cervical Cancer Screening) allowing internal and external comparisons. In some cases strong improvements of coverage after the introduction of an organised activity have been documented. Data, however, suggest a relevant heterogeneity of criteria for cytology interpretation, requiring actions to increase consistency. The impact of these transformations on incidence of cervical cancer will be observed in the future: preliminary results suggest a reduction in older programmes.

Measurement of the Cost of Screening for Cervical Cancer in the District of Florence, Italy

AIMS AND BACKGROUND

To estimate the cost per woman examined and per CIN II or more severe lesion detected in a population-based cytologic screening program for cervical cancer prevention. An organized cytologic screening program has been ongoing in the Florence District since 1973, and a call-recall system using mail invitation has been ongoing since 1980. Smear reading and assessment of screening positives is centralized at the screening unit.

METHODS AND STUDY DESIGN

All relevant resources (costs) consumed by the program were listed and measured. The unit cost per examined woman and per each CIN II or more severe lesion detected was estimated for each screening phase (recruitment, screening, assessment).

RESULTS

The cost per examined woman was $24.60, whereas that per CIN II or more severe lesion detected was $13,600. Staff accounted for 80% of total amount.

CONCLUSIONS

Although the cost for a single procedure is low, the cost per detected lesion is quite remarkable due to the low detection rate in a population screened for a long time. Different approaches and longer interval screening tests are discussed.