The positive predictive value of cervical smears in previously screened postmenopausal women: the Heart and Estrogen/progestin Replacement Study (HERS)

European consensus statement on expert colposcopy

BACKGROUND

Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease.

AIMS

To provide expert guidance on complex colposcopy cases through published evidence and expert consensus.

MATERIAL & METHODS

Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics.

RESULTS & DISCUSSION

The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

Hormonal Therapy for Gynecological Cancers: How Far Has Science Progressed toward Clinical Applications?

Simple Summary

The most common therapies for severe and recurrent gynecological cancers are hormone therapy and chemotherapy, and responsiveness to therapy is a key component in prognosis and survivability. Hormone therapy has recently been demonstrated to be an excellent cancer treatment approach. Hormone treatment for gynecological cancers is taking drugs that decrease hormone levels or impede their biological activity, halting or slowing cancer progression. Hormone therapy works by suppressing the multiplication of cancer cells triggered by hormones. Hormonal therapy, such as progestogens or tamoxifen, is frequently recommended for patients with hormone-sensitive recurrent or metastatic gynecological cancers, but response rates and therapeutic effects are inconsistent. Therefore, we discuss the pathogenesis of gynecological malignancies from the hormonal landscape and the use of hormonal therapies toward clinical applications.

Abstract

In recent years, hormone therapy has been shown to be a remarkable treatment option for cancer. Hormone treatment for gynecological cancers involves the use of medications that reduce the level of hormones or inhibit their biological activity, thereby stopping or slowing cancer growth. Hormone treatment works by preventing hormones from causing cancer cells to multiply. Aromatase inhibitors, anti-estrogens, progestin, estrogen receptor (ER) antagonists, GnRH agonists, and progestogen are effectively used as therapeutics for vulvar cancer, cervical cancer, vaginal cancer, uterine cancer, and ovarian cancer. Hormone replacement therapy has a high success rate. In particular, progestogen and estrogen replacement are associated with a decreased incidence of gynecological cancers in women infected with human papillomavirus (HPV). The activation of estrogen via the transcriptional functionality of ERα may either be promoted or decreased by gene products of HPV. Hormonal treatment is frequently administered to patients with hormone-sensitive recurring or metastatic gynecologic malignancies, although response rates and therapeutic outcomes are inconsistent. Therefore, this review outlines the use of hormonal therapy for gynecological cancers and identifies the current knowledge gaps.

Cervical Cancer Screening Outcomes Among a Sample of Low-Income Uninsured Women: A Program-Based Study

Background: Most studies examining cervical cancer screening outcomes have focused on either an age-specific diagnosis and outcomes of abnormal smears or frequency of abnormal outcomes among a sample of insured women. Thus, it is unclear what the distribution outcomes would be when other sociodemographic characteristics are considered. This study examines the variation in cervical cancer screening outcomes and sociodemographic characteristics (patients' age, marital status, race/ethnicity, rurality, and Papanicolaou [Pap] test screening history) within a sample of low-income and uninsured women.

Materials and Methods: Our grant-funded program provided 751 Pap tests, 577 human papillomavirus (HPV) tests, and 262 colposcopies to 841 women between 2013 and 2019. Observed outcomes for each procedure type were cross-tabulated by patients' sociodemographic characteristics. Chi-squared and Fisher's exact tests were used to test the independence of screening outcomes and sociodemographic characteristics.

Results: The overall positivity rate was 7.2% for Pap tests (n = 54/751), 3.6% for HPV tests (n = 21/577), and 44.7% for colposcopies (n = 117/262). Significance tests suggested that the Pap test and colposcopy outcomes we observed were independent of sociodemographic characteristics in all but one instance—Pap test outcomes were not independent of patient age (p = 0.009). Moreover, the Pap test positivity rate increased with patient age.

Conclusions: Our findings support recommendations to discontinue screening for women older than 65 years at low risk for cervical cancer. Our ability to identify an association between cervical screening outcomes and other sociodemographic characteristics may have been limited by our small sample size. This highlights an important barrier to studying health outcomes within low-income and uninsured populations, which are often missing in larger research data sets (e.g., claims).

Functional roles of female sex hormones and their nuclear receptors in cervical cancer

There has been little progress for several decades in modalities to treat cervical cancer. While the cervix is a hormone-sensitive tissue, physiologic roles of estrogen receptor α (ERα), progesterone receptor (PR), and their ligands in this tissue are poorly understood. It has hampered critical assessments of data in early epidemiologic and clinical studies for cervical cancer. Experimental evidence obtained from studies using mouse models has provided new insights into the molecular mechanism of ERα and PR in cervical cancer. In a mouse model expressing human papillomavirus (HPV) oncogenes, exogenous estrogen promotes cervical cancer through stromal ERα. In the same mouse model, genetic ablation of PR promotes cervical carcinogenesis without exogenous estrogen. Medroxyprogesterone acetate, a PR-activating drug, regresses cervical cancer in the mouse model. These results support that ERα and PR play opposite roles in cervical cancer. They further support that ERα inhibition and PR activation may be translated into valuable treatment for a subset of cervical cancers.

Cancer Screening Among Older Adults: a Geriatrician's Perspective on Breast, Cervical, Colon, Prostate, and Lung Cancer Screening

PURPOSE OF REVIEW

We summarize the evidence of benefits, harms, and tools to assist in individualized decisions among older adults in screening for breast, prostate, colon, lung, and cervical cancer.

RECENT FINDINGS

The benefits of cancer screening in older adults remain unclear due to minimal inclusion of adults > 75 years old in most randomized controlled trials. Indirect evidence suggests that the benefits of screening seen in younger adults (< 70 years old) can be extrapolated to older adults when they have an estimated life expectancy of at least 10 years. However, older adults, especially those with limited life expectancy, may be at increased risk for experiencing harms of screening, including overdiagnosis of clinically unimportant diseases, complications from diagnostic procedures, and distress after false positive test results. We provide a framework to integrate key factors such as health status, risks and benefits of specific tests, and patient preferences to guide clinicians in cancer screening decisions in older adults.

Practice Bulletin No. 168: Cervical Cancer Screening and Prevention

The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011 (1). The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease (2). Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year (3). When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed (4, 5).New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk-benefit considerations for women at different ages, as reflected in age-specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening (6), as did the U.S. Preventive Services Task Force (USPSTF) (7). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA) (8). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.

Cervical cancer screening among women ≥70 years of age in the United States-A referral problem or patient choice

OBJECTIVE

Clinical guidelines recommend that women with a history of adequate screening and not otherwise at high risk may discontinue cervical cancer screening after 65 years of age. However, screening remains common among US women over 65 years old. This study was conducted to examine whether overutilization was attributable to provider's recommendation or patient choice.

METHOD

This cross-sectional study used data from 1752 female participants (70+ years) from the 2013 National Health Interview Survey (NHIS). We quantitatively assessed the proportions of provider-recommended and patient self-initiated Pap smears.

RESULTS

Among female respondents, 40.8% had a Pap smear within the past 3 years, 19.4% had a Pap smear in the last year, and 39.7% reported receiving a recommendation for a Pap smear from their provider in the past year. Among women who received a recommendation to obtain a Pap smear, 39.8% did so within the past 12 months compared to 5.9% of women who did not receive a recommendation (adjusted odds ratio 10.5, 95% confidence interval 7.39-15.0). About 70% of women who visited an obstetrician/gynecologist and reported receiving a recommendation to have a Pap smear did so in the past year, while 32.3% of women who visited an obstetrician/gynecologist but did not receive a recommendation obtained one.

CONCLUSION

Pap smears were common among women ≥70 years of age. Health care providers may need additional education on current guidelines regarding indications for Pap smears in this age group to help reduce screening of patients who may not benefit.

Is Age an Independent Predictor of High-Grade Histopathology in Women Referred for Colposcopy after Abnormal Cervical Cytology?

This study was conducted to determine whether advancing age is an independent predictor of increased risk of high-grade pathologies among women referred for colposcopy after abnormal cervical cytology. Medical records were reviewed for women with abnormal cervical cytology who underwent colposcopy at Khon Kaen University Hospital. Logistic regression was used to determine the independent impact of age on the risk of high-grade pathologies. Mean age of the women was 42.8 years. Of 482 women, 97 (20.1%) were postmenopausal, and 92 (19.1%) were nulliparous. The rate of high-grade pathologies included cervical intraepithelial neoplasia 2-3, 99 (20.5%), adenocarcinoma in situ, 4 (0.8%), cervical cancer, 30 (6.2%), and endometrial cancer, 1 (0.2%). The prevalence of significant lesions was 26.9% (95% CI, 23.1%-31.2%). In total, 31 women had cancers (6.4%; 95% CI, 4.4%-9.0%). When controlling for smear types and parity, age was noted to be a significant independent predictor of high-grade histopathology. Women older than 35-40 years were approximately 2 times as likely to have severe histopathology as the younger women. This study illustrates the substantial risk of underlying significant lesions especially invasive cancer in Thai women with abnormal cervical cytology. Age was a significant independent factor predicting the risk of high-grade pathologies.

Cancer Screening in Older Adults

Cancer screening is an important tool for reducing morbidity and mortality in the elderly. In this article, performance characteristics of commonly used screening tests for colorectal, lung, prostate, breast, and cervical cancers are discussed. Guidelines are emphasized and key issues to consider in screening older adults are highlighted.

Cervical cancer prevention: immunization and screening 2015

Both primary and secondary prevention of cervical cancer are now available. Immunizations against human papillomavirus (HPV) types 16 and 18 have the potential to prevent 70% of cancers of the cervix plus a large percentage of other lower anogenital tract cancers. Screening guidelines were recently changed to recommend cotesting with cytology plus an HPV test. The addition of HPV testing increases the sensitivity and negative predictive value of screening over the Papanicolaou (Pap) test alone.

American cancer society guideline for the early detection of cervical neoplasia and cancer

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical neoplasia and cancer, based on recommendations from a formal review and recent workshop, is presented. The new screening recommendations address when to begin screening, when screening may be discontinued, whether to screen women who have had a hysterectomy, appropriate screening intervals, and new screening technologies, including liquid-based cytology and HPV DNA testing.

Counterpoint: cervical cancer screening guidelines--approaching the golden age

Changes in screening guidelines that imply suppression of procedures once recommended are always controversial because of the perception that benefits are being curtailed. Prior to 2012, cervical cancer screening guidelines issued by US-based expert bodies differed in several decision areas, making clinicians essentially cherry-pick among recommendations. To some extent, this approach to screening practices also served to shield clinicians from litigation. It implied starting screening earlier, doing it more frequently, and stopping later in life than necessary. This state of affairs changed in 2012, when the most influential professional groups updated their cervical screening guidelines, and recommendations became essentially unified. All groups recommended that women older than 65 years of age discontinue cervical cancer screening on the basis of evidence that screening benefits in this age group were minor and far outweighed by harms. The guidelines are very specific about the exceptions, which ensure acceptable safety. It is expected that the new guidelines will permit less wasteful cervical screening, while fostering the opportunity to direct resources towards ensuring adequate coverage of high-risk women.

Current recommendations for cervical cancer screening: do they render the annual pelvic examination obsolete?

The development of a screening test for cervical dysplasia has been a major force in diminishing the worldwide incidence of invasive cervical cancer. Screening intervals recommended by professional organizations have changed over the past half century. Recognition of the human papillomavirus (HPV) as the causative agent and enhanced understanding of the natural history of HPV and cervical dysplasia in different age groups have prompted the American College of Obstetricians and Gynecologists and other professional societies to defer Pap smear screening to intervals no less than 2 years apart in women 21-29, and every 3 years in women 30 and over assuming no prior history of cervical dysplasia. Screening should start no sooner than age 21. These recommendations more closely resemble those currently practiced in Europe and other parts of the developed world. Those who have undergone hysterectomy no longer need screening unless high-grade dysplasia was present. Although the value of pelvic examination is not debated in women with symptoms referable to the female genital tract, the endorsement by several professional societies of less than annual cervical cancer screening in healthy women also begs the question of whether annual pelvic examination (speculum and/or bimanual examination) benefits asymptomatic women. Some sexually transmitted infections are amenable to self-insertion of a vaginal probe or detectable by voided urine specimen. Bimanual examination is insensitive in detecting early ovarian cancer with a high false-positive rate leading to patient anxiety, excessive diagnostic testing, and unnecessary surgical procedures. Future study should focus on the frequency in which healthy asymptomatic women should undergo pelvic examination.

Modeling the impact of screening policy and screening compliance on incidence and mortality of cervical cancer in the post-HPV vaccination era

BACKGROUND

In Norway, pap smear screening target women aged 25-69 years on a triennial basis. The introduction of human papillomavirus (HPV) mass immunization in 2009 raises questions regarding the cost-saving future changes to current screening strategies.

METHODS

We calibrated a dynamic HPV transmission model to Norwegian data and assessed the impact of changing screening 20 or 30 years after vaccine introduction, assuming 60 or 90% vaccination coverage. Screening compliance among vaccinated women was assumed at 80 or 50%. Strategies considered: (i) 5-yearly screening of women of 25-69 years, (ii) 3-yearly screening of women of 30-69 years and (iii) 3-yearly screening of women of 25-59 years.

RESULTS

Greatest health gains were accomplished by ensuring a high vaccine uptake. In 2060, cervical cancer incidence was reduced by an estimated 36-57% compared with that of no vaccination. Stopping screening at the age of 60 years, excluding opportunistic screening, increased cervical cancer incidence by 3% (2060) compared with maintaining the current screening strategy, resulting in 1.0-2.4% extra cancers (2010-2060). The 5-yearly screening strategy elevated cervical cancer incidence by 30% resulting in 4.7-11.3% additional cancers.

CONCLUSION

High vaccine uptake in the years to come is of primary concern. Screening of young women <30 years remains important, even under the conditions of high vaccine coverage.

Correlation of histopathologic/cytologic follow-up findings with vaginal ASC-US and ASC-H Papanicolaou test and HPV test results

Current American Society of Colposcopy and Cervical Pathology recommendations about human papillomavirus (HPV) triage and further management for atypical squamous cells are pertinent to cervical Papanicolaou (Pap) tests. There are limited data on HPV detection in vaginal liquid-based cytology (LBC) specimens. The aims of this study were to determine whether adjunctive high-risk (HR)-HPV testing is useful for disease risk assessment in women with vaginal atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot exclude HSIL (ASC-H) Pap results. We identified 1,125 ASC-US and 36 ASC-H vaginal Pap results with HR-HPV testing. Of the cases, 244 (21.7%) ASC-US and 21 (58%) ASC-H were HR-HPV+. Among ASC-US HR-HPV+ cases, 47.8% had a squamous intraepithelial lesion (SIL) compared with 4.7% of HR-HPV- cases. Among ASC-H HR-HPV+ cases, 75% (12/16) had SIL compared with 31% (4/13) in HR-HPV- cases. Our results indicate that HPV triage testing is a reasonable and cost-effective approach for women with ASC-US vaginal Pap results and also a useful option for women with ASC-H vaginal Pap results.

Does hormone therapy, tibolone or raloxifene modify VEGF expression in cervical epithelial cells?

AIM

Vascular endothelial growth factor (VEGF) seems to be a critical molecule in cervical carcinogenesis. We aimed to investigate the possible associations between hormonal factors and VEGF expression in cervical epithelial cells from postmenopausal women.

METHOD

A total of 105 healthy postmenopausal women (aged 45-68 years old) attending a university menopause clinic were enrolled in this cross-sectional study. Pap smears were derived from current users of 17β-estradiol 1 mg + norethisterone acetate 0.5 mg (n = 28), tibolone 2.5 mg (n = 23), raloxifene HCl 60 mg (n = 21) and women not receiving treatment (n = 33). VEGF immunostaining was evaluated in squamous, glandular and metaplastic cells, using a semiquantitative method (rating scale: 0-3).

RESULTS

Concerning endogenous hormones, higher Δ4-androstenedione levels were associated with more intense VEGF immunostaining in glandular (p = 0.041) and metaplastic cells (p = 0.004). Hormone therapy and raloxifene did not induce any changes in VEGF immunoreactivity in the examined cells. In contrast, tibolone administration was accompanied by diminished VEGF presence in metaplastic cells (p = 0.016 vs. controls).

CONCLUSION

Our findings may in part reflect the molecular processes contributing to the safe profile of hormone therapy, tibolone and raloxifene in cervical carcinogenesis.

Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause

The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.

Significance of high-risk human papillomavirus DNA detection in women 50 years and older with squamous cell papanicolaou test abnormalities

CONTEXT

Data on cytologic screening and follow-up disproportionately reflect findings from frequently screened younger women, and data from screened women 50 years and older using newer screening technologies remain limited.

OBJECTIVE

To better understand the utility of adjunctive high-risk human papillomavirus (hrHPV) testing for disease risk stratification in women 50 years and older with a range of liquid-based cytology, abnormal, squamous cell Papanicolaou test results.

DESIGN

Liquid-based cytology cases interpreted as high-grade squamous intraepithelial lesion (HSIL); low-grade squamous intraepithelial lesion (LSIL); atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H); and atypical squamous cells of undetermined significance (ASC-US) at Magee-Womens Hospital (Pittsburgh, Pennsylvania) were retrospectively identified for a 36-month period between July 1, 2005, and June 30, 2008, from women 50 years and older who also had hrHPV DNA test results. Histopathologic follow-up diagnoses were analyzed.

RESULTS

During the study period, 4855 women 50 years and older had HSIL, LSIL, ASC-H, or ASC-US Papanicolaou test results and hrHPV testing. In 89.3% of HSIL cases, 71.0% of LSIL cases, 38.9% of ASC-H cases, and 14.2% of ASC-US cases, hrHPV test results were positive. The positive predictive value of a positive hrHPV test for histopathologic cervical intraepithelial neoplasia 2/3(+) detection was 90.5% with HSIL, 15% with ASC-H, 9.8% with LSIL, and 3.2% with ASC-US. A negative hrHPV test result had a 100% negative predictive value for histopathologic cervical intraepithelial neoplasia 2/3(+) in both LSIL and ASC-H cases.

CONCLUSIONS

In women 50 years and older, a positive hrHPV test result significantly increased the likelihood of follow-up histopathologic diagnoses of cervical intraepithelial neoplasia 2 /3(+) in patients with HSIL, LSIL, and ASC-H Papanicolaou test results compared with women with negative hrHPV test results. No cervical intraepithelial neoplasia 2/3(+) diagnoses were documented in women 50 years and older with LSIL or ASC-H Papanicolaou test results and negative hrHPV test results.

Estrogen and ERalpha: culprits in cervical cancer?

Estrogen and its receptors are implicated in the promotion and prevention of various cancers. Although the uterine cervix is highly responsive to estrogen, the role of estrogen in cervical cancer, which is strongly associated with human papillomavirus (HPV) infections, is poorly understood. Recent studies in HPV transgenic mouse models provide evidence that estrogen and its nuclear receptor promote cervical cancer in combination with HPV oncogenes. Although epidemiological studies further support this hypothesis, there is little experimental data assessing the hormonal responsiveness of human cervical cancers. If these cancers are dependent on estrogen, then drugs targeting estrogen and its receptors could be effective in treating and/or preventing cervical cancer, the second leading cause of death by cancer among women worldwide.

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women

OBJECTIVE

Guidelines support ending cervical cancer screening in women aged 65-70 years and older with previous normal testing, but little is known about older women's attitudes and beliefs about ending screening.

STUDY DESIGN

We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese, or Mandarin.

RESULTS

Most interviewees were nonwhite (44.7% Asian, 18.1% Latina, and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared with women in other ethnic groups (P < .01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded "yes."

CONCLUSION

The majority of these women believe that lifelong cervical cancer screening is important. Many women, however, reported that they would end screening if recommended by their physician.

The effects of tibolone in older postmenopausal women

BACKGROUND

Tibolone has estrogenic, progestogenic, and androgenic effects. Although tibolone prevents bone loss, its effects on fractures, breast cancer, and cardiovascular disease are uncertain.

METHODS

In this randomized study, we assigned 4538 women, who were between the ages of 60 and 85 years and had a bone mineral density T score of -2.5 or less at the hip or spine or a T score of -2.0 or less and radiologic evidence of a vertebral fracture, to receive once-daily tibolone (at a dose of 1.25 mg) or placebo. Annual spine radiographs were used to assess for vertebral fracture. Rates of cardiovascular events and breast cancer were adjudicated by expert panels.

RESULTS

During a median of 34 months of treatment, the tibolone group, as compared with the placebo group, had a decreased risk of vertebral fracture, with 70 cases versus 126 cases per 1000 person-years (relative hazard, 0.55; 95% confidence interval [CI], 0.41 to 0.74; P<0.001), and a decreased risk of nonvertebral fracture, with 122 cases versus 166 cases per 1000 person-years (relative hazard, 0.74; 95% CI, 0.58 to 0.93; P=0.01). The tibolone group also had a decreased risk of invasive breast cancer (relative hazard, 0.32; 95% CI, 0.13 to 0.80; P=0.02) and colon cancer (relative hazard, 0.31; 95% CI, 0.10 to 0.96; P=0.04). However, the tibolone group had an increased risk of stroke (relative hazard, 2.19; 95% CI, 1.14 to 4.23; P=0.02), for which the study was stopped in February 2006 at the recommendation of the data and safety monitoring board. There were no significant differences in the risk of either coronary heart disease or venous thromboembolism between the two groups.

CONCLUSIONS

Tibolone reduced the risk of fracture and breast cancer and possibly colon cancer but increased the risk of stroke in older women with osteoporosis. (ClinicalTrials.gov number, NCT00519857.)

Cervical cytology specimen adequacy: patient management guidelines and optimizing specimen collection

OBJECTIVE

To provide updated management guidelines according to cervical cytology specimen adequacy and techniques to optimize adequacy based on literature review and expert opinion.

MATERIALS AND METHODS

Selected members of the American Society for Colposcopy and Cervical Pathology committee and invited experts conducted a literature review and discussed appropriate management and areas for future research emphasis.

RESULTS

The guidelines recommend a repeat Pap test in a short interval of 2 to 4 months for most women when the cytology result is unsatisfactory. The preferred follow-up for women with a negative cytology result lacking an endocervical/transformation zone component or showing other quality indicators is a repeat Pap test in 12 months. Indications for an early repeat Pap test in 6 months are provided, and the influence of human papillomavirus testing results on management is discussed. Techniques for optimizing specimen adequacy are provided in detail.

CONCLUSION

The specimen adequacy management guidelines will help promote uniform and optimal follow-up of patients receiving cervical cytology screening. The topics for future research emphasis will be helpful in promoting studies in needed areas.

[Trend of socioeconomic inequality in participation in cervical cancer screening among Korean women]

OBJECTIVES

While cervical cancer is one of the leading cancers among women worldwide, there are a number of effective early detection tests available. However, the participation rates in cervical cancer screening among Korean women remain low. After the nationwide efforts in 1988 and thereafter to encourage participation in cervical cancer screening, few studies have investigated the effects of socioeconomic inequality on participation in cervical cancer screening. The purpose of this study was to investigate 1) the level of socioeconomic disparities in receiving cervical cancer screening by age group and 2) if there was an improvement in reducing these disparities between 1995 and 2001.

METHODS

Using data from the Korean National Health Status, Health Behavior and Belief Survey in 1995, and the Korean National Health and Nutrition Examination Surveys from 1998 and 2001 (sample sizes of 2,297, 3,738, and 3,283), age-standardized participation rates were calculated according to education level, equivalized household income, and job status. Odds ratios and the relative inequality index (RII) were also calculated after controlling for age.

RESULTS

Women with lower education levels were less likely to attend the screening test, and the disparities by education level were most pronounced among women aged 60 years and older. The RIIs among women 60 years and older were 3.64, 4.46, and 8.64 in 1995, 1998, and 2001, respectively. Higher rates of participation were reported among those in the highest income category, which was more notable among the middle aged women (40s and 50s). An inconsistent trend in the rate of participation in cervical cancer screening by occupational level was found.

CONCLUSIONS

Indicators of socioeconomic position seem to have varying impacts on the inequalities in the rates of participation in cervical cancer screening according to age group. These results demonstrate the need for more aggressive and age-based interventions and policy programs to eliminate the remaining inequalities.

Utility of toluidine blue in oral premalignant lesions and squamous cell carcinoma: Continuing research and implications for clinical practice

Toluidine blue (TB) has been shown to aid in the detection and diagnosis of oropharyngeal squamous cell carcinoma (OSCC) and oral premalignant lesions (OPLs). TB has been shown to enhance visualization of oral lesions and assist in identifying sites of increased risk of dysplastic/malignant change and promote biopsy. TB has been shown to identify lesions with molecular changes associated with risk of progression of OPLs to OSCC. A recent prospective longitudinal study showed TB retention in histologic benign lesions and lesions with mild dysplasia that are at increased risk of progression to cancer. Clinical trials show that TB is useful in identifying asymptomatic OSCC and premalignant lesions at risk of progressing to SCC, which might otherwise be undetected until lesions become more advanced. The data supports TB use in oral examination of patients at risk of OSCC.

Common Gynecologic Problems in Geriatric-aged Women

Gynecologic concerns in postmenopausal women are common. Although various conditions may affect all women in this age group, the prevalence of certain disorders, and also diagnostic approaches and treatment options, may vary significantly when considering very elderly women compared with those early in the sixth decade. The focus of this chapter is to address several commonly encountered gynecologic issues in postmenopausal women, with particular attention given to aspects that must be considered when caring for women in the geriatric age group.

E-cadherin expression in cervical epithelial cells of postmenopausal women: association with hormone therapy, tibolone, and raloxifene

This study assesses the possible associations between postmenopausal therapy (hormone therapy, raloxifene, and tibolone) and E-cadherin expression in normal cervical Papanicolaou smears (squamous, glandular, and metaplastic cells). E-cadherin immunostaining was less intense in metaplastic cells of women on tibolone, whereas hormone therapy and raloxifene were not associated with altered E-cadherin expression.

Cytohormonal and morphological alterations in cervicovaginal smears of postmenopausal women on hormone replacement therapy

The objective of the study was to study the cytohormonal and morphological alterations in cervicovaginal smears associated with the use of hormone replacement therapy (HRT) and to assess the utility of vaginal cytology in determining the response to HRT. Ninety postmenopausal women (30 on estrogen-progesterone combination (HRT) for 1 to 24 mo (user 1), 30 on estrogen therapy (ERT) for 1 to 44 mo (user 2), and 30 not on any hormones (nonusers)) were included in the cross-sectional study. Their lateral vaginal wall smears and cervical smears were examined for hormonal and morphological assessments, respectively. The smear pattern showed predominance of parabasal cells in 46.6% of nonusers, while none of the users had >70% parabasal cells. A high percentage (>70%) of intermediate cells was found in 46.6% of users and only in 16.6% of nonusers. A high maturation value (MV) was found in more than 75% of users but in only 16.6% of nonusers. The women with high MV (>50) were significantly less symptomatic than did nonusers. Atrophic changes were present in cervical smears of 14/20 (46.6%) nonusers when compared with 1/60 (1.66%) users. Atypical squamous cells of undetermined significance (ASC-US) were diagnosed in seven users and three nonusers. It persisted on follow-up in four users and one nonuser. Histology revealed one mild dysplasia among users. Lactobacilli were more frequently observed in users. The cytohormonal pattern on vaginal smears correlates well with the response to hormonal therapy and clinical symptoms. Awareness of the morphological alterations associated with the use of replacement hormones would enable the cytologists to reduce the false-positive diagnoses while evaluating postmenopausal smears.

Clinical significance of cytologic diagnosis of atypical squamous cells, cannot exclude high grade, in perimenopausal and postmenopausal women

We used cytohistologic correlation to determine the clinical significance of atypical squamous cells, cannot exclude high grade (ASC-H) in perimenopausal and postmenopausal women. A computer search identified 250 Papanicolaou smears from women older than 45 years with a diagnosis of ASC- H. Cases were considered perimenopausal (45 to < 55 years; 150 cases) and postmenopausal ((3)55 years; 100 cases). No follow-up data were available for 33 cases, which were excluded. The remaining 217 cases (perimenopausal, 127; postmenopausal, 90) had surgical or cytologic follow-up. Results of follow-up colposcopic biopsy were available for 176 (81.1%) and cytology for 41 (18.9%) women. Follow-up results were as follows: perimenopausal women, negative, 50 (39.4%); mild dysplasia (low-grade squamous intraepithelial lesion [LSIL]), 46 (36.2%); high-grade dysplasia (high-grade SIL [HSIL]); 28 (22.0%); and ASC of undetermined significance (ASC-US), 3 (2.4%); postmenopausal women, negative, 52 (58%); LSIL, 31 (34%); HSIL, 5 (6%); and ASC-US, 2 (2%). The diagnosis of ASC-H in postmenopausal women usually is associated with LSIL or a negative diagnosis on follow-up, suggesting a less aggressive surveillance and treatment regimen is needed for postmenopausal women with ASC-H.

Incidence of Cervical Cytological Abnormalities With Aging in the Women’s Health Initiative

OBJECTIVE

To estimate the incidence of cytological abnormalities and cervical cancer and to determine the effect of oral estrogen and progestin on cervical cytology among postmenopausal women participating in a multi-institution clinical trial.

METHODS

The study was a longitudinal analysis of a prospective cohort of 16,608 postmenopausal women (aged 50-79 years) participating in the Women's Health Initiative (WHI) clinical trial of estrogen plus progestin. Eligible participants had a cervical smear within 1 year before randomization and at 3- and 6-year follow-ups. Outcomes measured were low-grade and high-grade squamous intraepithelial lesions (LSIL, HSIL) and cervical cancer at follow-up years 3 and 6.

RESULTS

Of 15,733 eligible participants with a uterus, 7,663 were assigned to placebo and 8,070 to estrogen plus progestin. At baseline, 318 women (2%) had low-grade abnormalities on cervical cytology. The annual incidence rate of any new cytological abnormality in the estrogen plus progestin group was significantly higher than that in the placebo group (hazard ratio 1.4, 95% confidence interval [CI] 1.2-1.6). Independent risk factors for HSIL and cervical cancer over a 6-year follow-up (after stratifying for baseline cytologic abnormalities) included sexual activity in the past year while not being married or living as married (hazard ratio 3.5, 95% CI 1.5-8.3). Risk factors did not include age or use of estrogen plus progestin.

CONCLUSION

Use of estrogen plus progestin was associated with increased incidence of any cytologic abnormality, although it had no impact on the incidence of HSIL or cervical cancer. Sexually active older women who are not married or living as married may benefit from continued cervical cancer screening.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, www.clinicaltrials.gov, NCT00000611.

Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence

There is general consensus that screening can reduce mortality from colorectal, breast, and cervical cancer among persons in their 50s and 60s. However, few screening trials have included persons over age 70 years. Therefore, indirect evidence must be used to determine when results in younger persons should be extrapolated to older persons. In this review, we focus on cancer screening tests that are well accepted in younger persons (mammography, Papanicolaou smears, and colorectal cancer screening) and discuss the strength of inference concerning benefits and harms of screening older persons. Some aspects of aging favor screening (eg, increased absolute risk of dying of cancer) whereas other aspects do not (eg, decreased life expectancy). Age also affects the behavior of some cancers (eg, increases the proportion of slow-growing breast cancers) and affects the accuracy of some screening tests (eg, increases the accuracy of mammography; decreases the accuracy of sigmoidoscopy). These effects make the application of evidence in younger populations to older populations complex. However, given the heterogeneity of the elderly population, there is no evidence of one age at which potential benefits of screening suddenly cease or potential harms suddenly become substantial for everyone. Therefore, characteristics of individual patients that go beyond age should be the driving factors in screening decisions. For example, persons who have a life expectancy less than 5 years or persons who would decline treatment should generally not be screened. Decisions to either continue or discontinue screening in the elderly should be based on health status, the benefits and harms of the test, and preferences of the patient, rather than solely on the age of the patient.

Reflex human papilloma virus infection testing detects the same proportion of cervical intraepithelial neoplasia grade 2-3 in young versus elderly women

BACKGROUND

The American Society for Colposcopy and Cervical Pathology recently recommended triage of women with atypical squamous cells of undetermined significance (ASCUS) through reflex human papilloma virus (HPV) infection testing. Because age is an important determinant of the incidence of both ASCUS and HPV infection, the current study was conducted to determine the impact of age on reflex HPV infection test performance.

METHODS

The authors reviewed all liquid-based Papanicolaou tests submitted for reflex HPV infection testing to the University of Alabama Medical Center during the period from January 2002 to January 2004. To assess the impact of age on reflex HPV infection testing, women were divided into 6 age groups (<25, 25-34, 35-44, 45-54, 55-64, >64 years). Trend of different diagnostic categories with age was assessed using the chi-square test for linear trend. As a measure of test performance, the proportions of cervical intraepithelial neoplasia (CIN) lesions confirmed by biopsy through reflex testing (of the total CIN lesions detected in the study population) were then compared among different age groups.

RESULTS

During the study period, 25,164 ThinPrep tests were performed during the study period, with 2672 (11%) cases of ASCUS and 1371 (5%) cases of squamous intraepithelial lesions (SILs). A total of 2309 (86%) ASCUS cases were tested for HPV infection, of which 789 (34%) were positive. Biopsy specimens were obtained from 831 patients with SILs and from 316 patients with HPV+ASCUS. Of 246 patients with CIN Grade 2-3 (CIN2-3) detected on biopsy, 36 (15%) were triaged through reflex HPV infection testing and the rest were triaged through cytologic diagnosis of SILs. Despite the trend in the prevalence of HPV+ASCUS and SILs with increasing age (P < 0.05), there was no significant difference in the proportion (range, 9-23%) of CIN2-3 detected through reflex HPV infection testing in different age groups.

CONCLUSIONS

Reflex HPV infection testing performed similarly for women in different age groups, including perimenopausal and postmenopausal women.

Screening for cervical cancer: will women accept less?

BACKGROUND

U.S. professional organizations increasingly agree that most women require Papanicolaou smear screening every 2 to 3 years rather than annually and that most elderly women may stop screening. We sought to describe the attitudes of women in the United States toward less intense screening, specifically, less frequent screening and eventual cessation of screening.

METHODS

We conducted a random-digit-dialing telephone survey of women in 2002 (response rate of 75% among eligible women reached by telephone). A nationally representative sample of 360 women aged 40 years or older with no history of cancer was surveyed about their acceptance of less intense screening.

RESULTS

Almost all women aged 40 years or older (99%) had had at least one Pap smear; most (59%) were screened annually. When women were asked to choose their preferred frequency for screening, 75% preferred screening at least annually (12% chose screening every 6 months). Less than half (43%) had heard of recommendations advocating less frequent screening. When advised of such recommendations, half of all women believed that they were based on cost. Sixty-nine percent said that they would try to continue being screened annually even if their doctors recommended less frequent screening and advised them of comparable benefits. Only 35% of women thought that there might come a time when they would stop getting Pap smears; of these, almost half would not stop until after age 80 years. The strongest predictor of reluctance to reduce the frequency of screening was a belief that cost was the basis of current screening frequency recommendations.

CONCLUSION

Most women in the United States prefer annual Pap smears and are resistant to the idea of less intense screening. Concern that cost considerations rather than evidence form the basis of screening recommendations may partly explain women's reluctance to accept less intense screening.

Current cervical neoplasia screening practices of obstetrician/gynecologists in the US

OBJECTIVE

The purpose of this study was to determine cervical cancer screening practices of obstetrician/gynecologists in the US after recent revised guidelines.

STUDY DESIGN

Questionnaires were mailed to 355 randomly selected US obstetrician/gynecologists. Questions were structured as clinical vignettes.

RESULTS

Questionnaires were returned by 60% (213/355) of recipients; 185 were eligible. Seventy-four percent would begin screening virginal girls at age 18. Sixty percent would continue annual screening in a 35-year-old woman with 3 or more normal tests. Frequent screening is common in women after total hysterectomy for symptomatic fibroids and no history of dysplasia, and in 70-year-old women with a 30-year history of previous normal tests. Most (82%) use liquid-based cytology; 78% of female respondents would prefer it for themselves. Most (64%) would not adopt triennial Pap/HPV DNA screening, although 58% of women would choose it for themselves.

CONCLUSION

Most US obstetrician/gynecologists screen low-risk women often and indefinitely, despite national guidelines designed to minimize screening harms resulting from overtesting.

Diagnoses and outcomes in cervical cancer screening: a population-based study

OBJECTIVE

This study was undertaken to examine routine cervical cancer screening diagnoses and outcomes on an age-specific basis in a US population.

STUDY DESIGN

We conducted an observational cohort study using 1997-2002 health plan administrative and laboratory data for women enrolled at Kaiser Permanente Northwest (Portland, Ore) in 1998.

RESULTS

Across all female enrollees (n=150,052), the annual rate of routine cervical cancer screening was 294.7 per 1,000, with cytologic abnormalities detected at a rate of 14.9 per 1,000. The annual incidence of cervical intraepithelial neoplasia (CIN) 1 was 1.2 per 1,000 with a rate of 1.5 per 1,000 for CIN 2/3. CIN 1 incidence peaked among women aged 20 to 24 years (5.1 per 1,000), with CIN 2/3 rates highest among those 25 to 29 years (8.1 per 1,000). From among 44,493 routine cervical smears, results were normal for 94.5%, with abnormal diagnoses of atypical squamous cells (3.3%), atypical glandular cells (0.2%), low-grade squamous intraepithelial lesion (1.2%), high-grade squamous intraepithelial lesion (0.3%), and inconclusive/inadequate (0.5%). Of women with abnormal routine smears, CIN or cancer was detected on follow-up in 19.4% of cases, 51.5% were found to have had a false-positive smear, and 29.0% incomplete follow-up as defined by published management guidelines.

CONCLUSION

These are the first comprehensive age-specific estimates of routine cervical cancer screening diagnoses and outcomes to be reported within a US general healthcare setting. Overall, 5% of routinely screened women were found to have an abnormal cervical smear with an annual incidence of CIN across all female enrollees of 2.7 per 1000.

The frequency of Pap smear screening in the United States

BACKGROUND

U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening.

OBJECTIVE

To describe the frequency of cervical cancer screening in the United States.

DESIGN

National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics.

PARTICIPANTS

Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467).

MEASUREMENTS

Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years.

RESULTS

The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening-38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher-80% undergo annual screening, with only a modest decline in screening frequency with increasing age.

CONCLUSIONS

The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.

Risk of cervical cancer associated with extending the interval between cervical-cancer screenings

BACKGROUND

Although contemporary guidelines suggest that the intervals between Papanicolaou tests can be extended to three years among low-risk women with previous negative tests, the excess risk of cervical cancer associated with less frequent than annual screening is uncertain.

METHODS

We determined the prevalence of biopsy-proven cervical neoplasia among 938,576 women younger than 65 years of age, stratified according to the number of previous consecutive negative Papanicolaou tests. Using a Markov model that estimates the rate at which dysplasia will progress to cancer, we estimated the risk of cancer within three years after one or more negative Papanicolaou tests, as well as the number of additional Papanicolaou tests and colposcopic examinations that would be required to avert one case of cancer given a particular interval between screenings.

RESULTS

Among 31,728 women 30 to 64 years of age who had had three or more consecutive negative tests, the prevalence of biopsy-proven cervical intraepithelial neoplasia of grade 2 was 0.028 percent and the prevalence of grade 3 neoplasia was 0.019 percent; none of the women had invasive cervical cancer. According to our model, the estimated risk of cancer with annual Papanicolaou tests for three years was 2 in 100,000 among women 30 to 44 years of age, 1 in 100,000 among women 45 to 59 years of age, and 1 in 100,000 among women 60 to 64 years of age; these risks would be 5 in 100,000, 2 in 100,000, and 1 in 100,000, respectively, if screening were performed once three years after the last negative test. To avert one additional case of cancer by screening 100,000 women annually for three years rather than once three years after the last negative test, an average of 69,665 additional Papanicolaou tests and 3861 colposcopic examinations would be needed in women 30 to 44 years of age and an average of 209,324 additional Papanicolaou tests and 11,502 colposcopic examinations in women 45 to 59 years of age.

CONCLUSIONS

As compared with annual screening for three years, screening performed once three years after the last negative test in women 30 to 64 years of age who have had three or more consecutive negative Papanicolaou tests is associated with an average excess risk of cervical cancer of approximately 3 in 100,000.

Positive predictive value of liquid-based and conventional cervical Papanicolaou smears reported as malignant

OBJECTIVES

The predictive value of cervical Papanicolaou (Pap) smears reported as "positive for malignancy," especially those obtained by the liquid-based method, has not been adequately assessed. The objectives of this study are to determine the positive predictive value of Papanicolaou smears with features of malignancy, to compare the accuracy of Papanicolaou smears obtained by the liquid-based method to those obtained by the conventional technique in this setting, and to study the factors influencing a false-positive cytologic diagnosis of malignancy.

MATERIALS AND METHODS

Pap smears significant for malignant cytology were identified at Fletcher Allen Health Care Hospital in Burlington, VT, from May 1, 1995, to April 30, 2001. A retrospective review of the hospital records and pathology reports was performed documenting patient characteristics, the collection technique, and the final histology. An independent review of the cytology and histology was performed. The positive predictive value and false-positive rate of malignant cytology were calculated for the liquid-based and conventional Pap smear techniques.

RESULTS

A total of 472,743 Pap smears were performed during the period specified. One hundred four Pap smears were reported as positive for malignancy, yielding a prevalence rate of 0.02%. A total of 68 patients had paired cytology and histology specimens. Malignant cytology was identified in 36 smears obtained by the liquid-based technique and 32 smears obtained by the conventional technique. A true-positive result, meaning malignant cytology confirmed by the presence of invasive carcinoma on histology, was obtained in 61 of 68 (89.7%) patients. A false-positive result, meaning malignant cytology not confirmed by histology, was obtained in 7 of the 68 (10.3%) patients. The false-positive rate of malignant cytology was 8.4% for the liquid-based technique and 12.5% for the conventional technique. All 7 false-positive smears were diagnosed with high-grade dysplasia by histology. Three of the 7 patients with high-grade dysplasia had previous treatment for dysplasia, one of whom was also pregnant at the time of the smear.

CONCLUSIONS

Malignant cervical Papanicolaou smear cytology has a high positive predictive value in the setting of gynecologic and nongynecologic malignancies. Previous treatment for cervical dysplasia or pregnancy may influence the false-positive rate of malignant cytology.

Histologic findings from the cervix among older women with abnormal cervical cytology

OBJECTIVE

The aim of this study was to determine rates of cervical neoplasia among women at least 50 years of age referred for colposcopy after abnormal cytology and to compare these to younger women.

METHODS

From a prospectively accrued database of 2825 women undergoing colposcopy in the gynecology clinic of an urban public hospital, women at least 50 years of age with a known cytologic abnormality were selected for retrospective analysis. Demographic and medical information collected at colposcopy and subsequent histology was reviewed. Cytology results were based on the Bethesda system, and histology was reported as grades of cervical intraepithelial neoplasia (CIN). Statistical analysis was by t test, chi(2) test, and Mann-Whitney U test.

RESULTS

Among 325 women at least age 50, cervical histologic results were benign or atypical for 147 (45%), CIN1 for 28 (9%), CIN2 for 21 (6%), CIN3 for 49 (15%), cancer for 11 (3%), and ungraded dysplasia for 7 (2%), with no biopsy performed for 62 (19%) women. Symptoms were more common among women with cancer (6/11 or 55%) than those without (62/263 or 21%, P = 0.01). Negative histology (80/231 or 35%), CIN3 (49/231 or 21%), and cancer (9/231 or 4%) were more common among older than younger women (287/1403 or 20%, 199/1403 or 14%, and 11/1403 or 1%, respectively), while atypia (438/1403 or 31%), CIN1 (321/1403 or 23%), and CIN2 (147/1403 or 10%) were more common among younger than older women (53/231 or 23%, 23/231 or 10%, and 17/231 or 7%, respectively, P < 0.04). Differences in the distribution of cervical histology results remained significant among women with ASCUS (P = 0.001) but not those with LSIL (P > 0.9), HSIL (P > 0.07), or cancer (P > 0.4).

CONCLUSIONS

Most older women are referred for colposcopy with lesser grades of abnormality, but cervical cancers are found across all cytologic grades and were more common in symptomatic women. Compared to younger women with abnormal cytology, women at least 50 years of age with ASCUS had higher rates of negative evaluations and high grade but not low- or mid-grade lesions.

Estimating the influence of rescreening interval on the benefits associated with cancer screening: approaches and limitations

ABSTRACT Randomized controlled trials that seek to measure the ability of a screening test to lower cancer mortality generally do not provide data that bear on the relative efficacy of different screening intervals. Guidance regarding the choice of a screening interval that achieves a high level of case-finding, without being excessively costly, can be obtained from one or more of several study designs that examine the subsequent occurrence of cancer in persons who have had a negative screening test. However, each of these can potentially provide a misleading result, and so their limitations must be considered before using the data they generate to develop a rational rescreening policy.

Screening for cervical disease in mature women: strategies for improvement

BACKGROUND

Cervical carcinoma remains a significant health risk for the older woman. In the current study the yield of screening of mature women in an established, opportunistic screening program was examined. Strategies for improving screening in this age group were identified through examination of recent Pap test history of women with high grade squamous intra-epithelial lesions (HSIL).

METHODS

From the population based registry of the Ontario Cervical Screening Program, the Pap test cytodiagnoses for almost 700,000 women screened during the first six months of 2000 were classified by age quintile. Screening yields for younger women (< 50 years of age) and mature women (>/= 50 years of age) were compared using the detection ratio (abnormalities per 1000 women tested). Any pap test results during the three years preceding a diagnosis of HSIL in mature women were identified (excluding any Pap test in the six months immediately prior to the HSIL cytodiagnosis) and classified into one of three categories: no prior test known, prior negative Pap test known, and prior abnormal Pap test known.

RESULTS

Twenty four percent of all Pap tests in the six month period were from mature women. Approximately 11% of all cytodiagnoses of HSIL and carcinoma (HSIL+), and 13% of all low grade squamous intra-epithelial lesions (LSIL), HSIL, carcinoma, and atypical glandular cells of uncertain significance (AGUS); [LSIL+ and AGUS] cytodiagnoses, were from mature women. The yield of Pap testing in mature women (1.7 HSIL+ per 1000 women tested) was slightly more than 40% of that for younger women (4.2 HSIL+ per 1000 women tested). Mature women with HSIL were more likely to have had a history of no prior screening (61.1%) than younger women (49.5%). The majority (62.9%) of mature women with HSIL and a prior known Pap test had a prior registered abnormal Pap test.

CONCLUSIONS

Pap testing of mature women yields a significant number of abnormalities, but is less efficient than Pap testing of younger women. Screening yield could be increased by recruiting mature women who are currently inadequately screened and by revising guidelines for cessation of screening. Proper followup of mature women with Pap test abnormalities would improve clinical outcome but could adversely affect the yield of Pap testing, since current inappropriate repeat testing of women would decrease.