Calendar-period trends in cervical precancer and cancer diagnoses since the introduction of human papillomavirus and cytology co-testing into routine cervical cancer screening at Kaiser Permanente Northern California.

OBJECTIVES: The longer-term impact of introducing human papillomavirus (HPV) testing into routine cervical cancer screening on precancer and cancer rates by histologic type has not been well described. Calendar trends in diagnoses were examined using data from Kaiser Permanente Northern California, which introduced triennial HPV and cytology co-testing in 2003 for women aged ≥30 years. METHODS: We examined trends in cervical precancer (cervical intraepithelial neoplasia grade 3 [CIN3] and adenocarcinoma in situ [AIS]) and cancer (squamous cell carcinoma [SCC] and adenocarcinoma [ADC]) diagnoses per 1000 screened during 2003-2018. We examined ratios of squamous vs. glandular diagnoses (SCC:ADC and CIN3:AIS). RESULTS: CIN3 and AIS diagnoses increased approximately 2% and 3% annually, respectively (ptrend < 0.001 for both). While SCC diagnoses decreased by 5% per annually (ptrend < 0.001), ADC diagnoses did not change. These patterns were generally observed within each age group (30-39, 40-49, and 50-64 years). ADC diagnoses per 1000 screened did not change even among those who underwent co-testing starting in 2003-2006. SCC:ADC decreased from approximately 2.5:1 in 2003-2006 to 1.3:1 in 2015-2018 while the CIN3:AIS remained relatively constant, ∼10:1. CONCLUSIONS: Since its introduction at KPNC, co-testing increased the detection of CIN3 over time, which likely caused a subsequent reduction of SCC. However, there has been no observed decrease in ADC. One possible explanation for lack of effectiveness against ADC is the underdiagnosis of AIS. Novel strategies to identify and treat women at high risk of ADC need to be developed and clinically validated.

Trends in the use of cervical cancer screening tests in a large medical claims database, United States, 2013-2019.

OBJECTIVE: To examine trends in the use of cervical cancer screening tests during 2013-2019 among commercially insured women. METHODS: The study population included women of all ages with continuous enrollment each year in the IBM MarketScan commercial or Medicare supplemental databases and without known history of cervical cancer or precancer (range = 6.9-9.8 million women per year). Annual cervical cancer screening test use was examined by three modalities: cytology alone, cytology plus HPV testing (cotesting), and HPV testing alone. Trends were assessed using 2-sided Poisson regression. RESULTS: Use of cytology alone decreased from 34.2% in 2013 to 26.4% in 2019 among women aged 21-29 years (P < .0001). Among women aged 30-64 years, use of cytology alone decreased from 18.9% in 2013 to 8.6% in 2019 (P < .0001), whereas cotesting use increased from 14.9% in 2013 to 19.3% in 2019 (P < .0001). Annual test use for HPV testing alone was below 0.5% in all age groups throughout the study period. Annually, 8.7%-13.6% of women aged 18-20 years received cervical cancer screening. There were persistent differences in screening test use by metropolitan residence and census regions despite similar temporal trends. CONCLUSIONS: Temporal changes in the use of cervical cancer screening tests among commercially insured women track changes in clinical guidelines. Screening test use among individuals younger than 21 years shows that many young women are inappropriately screened for cervical cancer.

Cervical Screening Practices and Outcomes for Young Women in Response to Changed Guidelines in Calgary, Canada, 2007-2016.

OBJECTIVE: The aim of the study was to describe temporal trends in screening and outcomes for women, after changes in guidelines in Alberta, Canada, that raised starting age to 21 years, then to 25 years of age, and reduced frequency to 3 yearly. MATERIALS AND METHODS: Calgary Laboratory Information System data were used to examine screening rates, follow-up procedures, and cancer among women 10-29 years from 2007 to 2016 in the whole population of Calgary. Interrupted time-series analyses were used to assess changes in screening and subsequent diagnostic procedures over the 10-year period. RESULTS: Annual screening rates dropped by approximately 10% at all ages older than 15 years after the 2009 Alberta cervical cancer screening guidelines, followed by a steady decrease. Further change continued subsequent to minimal apparent effect of the 2013 Canadian Task Force on Preventive Health Care guidelines. The rates of abnormal test results decreased in concert with decreased screening. No increases in cervical intraepithelial neoplasia 1, cervical intraepithelial neoplasia 2/3, or invasive cervical cancer rates were observed after reduced testing. CONCLUSIONS: The largest decrease in screening and follow-up procedures occurred in the period immediately after implementation of 2009 Alberta screening guidelines. The number of consequent procedures also decreased in proportion to decreased screening, but there was no increase in cancer rates. Starting screening at the age of 25 years and reducing intervals seem to be safe.

Pathway to the Papanicolaou smear: The development of cervical cytology in twentieth-century America and implications in the present day.

George Papanicolaou, a Greek immigrant and cytopathologist, was responsible for what is now colloquially known as the "Pap smear"-undoubtedly one of the greatest advances in medicine and public health of the last century. However, his landmark research on the development of cervical cytology for the detection of precancerous lesions of the cervix ("New Cancer Diagnosis," 1928) made a rather inauspicious debut in an unlikely venue: John Harvey Kellogg's Third Race Betterment Conference-a meeting devoted to the furtherance of the concept and implementation of eugenics. Herein, we discuss the stark juxtaposition of Papanicolaou's landmark discovery amid the pseudoscience of the third Race Betterment Conference. We discuss the latency of Papnicolaou's discovery-its potential implications unrealized-until co-publication with Herbert Traut, which catapulted Papanicolaou's research to the scientific foreground. This gave rise to public health initiatives aimed at establishing the Pap smear as a screening tool. We further delineate the progress made in recent decades with the identification of HPV as the etiological agent for cervical cancer, and the subsequent development of the HPV vaccine, and discuss ongoing research in the present day. In this way, we hope to provide a background and historical context for the development of the Pap smear.

Trend analysis of the quality indicators for the Brazilian cervical cancer screening programme by region and state from 2006 to 2013.

BACKGROUND: Quality indicators for the Brazilian cervical cancer screening programme can provide a perspective on its effectiveness in Brazilian macro-regions and states. The aim of this study was to perform a trend analysis of the cervical cancer screening program's quality indicators, according to Brazilian regions and states, from 2006 to 2013. METHODS: Using information from approximately 62,000,000 exams obtained from the Information System of Cervical Cancer Screening (SISCOLO), joinpoint analysis was used to calculate the Annual Percentage Change (APC). RESULTS: The estimated number of women in the target age group (25-64 years) who underwent Pap testing over a three-year interval was lower than that recommended by international guidelines in the North, Northeast and Midwest regions, and the trends for this indicator remained stationary over the years in all regions of Brazil. Overall, the index of positivity in Brazilian regions and states is below that preconized by the Brazilian National Cancer Institute (INCA). Additionally, the frequencies of unsatisfactory cases are in line with international guidelines but above those preconized by INCA guidelines. All positive cytological diagnoses were lower than those preconized by INCA. CONCLUSIONS: The results show that the cervical cancer screening programme is still far from efficient because most of the quality indicators in Brazilian regions and states are outside of the parameters preconized by national and international organizations.

CERVICAL CYTOLOGY TRENDS IN A SAMPLE OF INFLAMMATORY BOWEL DISEASE PATIENTS IN PUERTO RICO: A DESCRIPTIVE STUDY AND RESEARCH OF CURRENT LITERATURE.

OBJECTIVE OF THE STUDY: To describe cervical cytology trends in a sample of patients with Inflammatory Bowel Disease (IBD) and to provide an overview of aspects such as contraception and menstrual patterns. STUDY DESIGN: We identified women with diagnosis of IBD of ages between 21-49 years followed at the IBD clinics of the Medical Sciences Campus from June 2012 to April 2014. A 15-minute questionnaire was administered. Data was entered and analyzed calculating frequencies and percentages. RESULTS: Sixty-three subjects were recruited. After reviewing the questionnaires, 52 subjects remained for analysis. All women were between 21 and 49 years of age. Thirty (58%) patients had a diagnosis of ulcerative colitis (UC), while 22 (42%) patients had Crohn's Disease (CD). Twenty-seven IBD patients (52%) were in remission. Use of immunomodulators was reported in ten (33%) and seventeen (61%) of patients for UC and CD respectively. Sixty six percent (67%) of participants specified having their cervical cytology for cervical cancer screening done a nually. Twenty patients (38%) reported abnormal cytology including 13 patients (43%) with UC and 7 patients (23%) with CD. No significant relation was found between the two conditions and the self-reported history of abnormal cervical cytology. Almost one-half of IBD patients reported a menstrual cycle of 25-30 days (45%). Duration of menses was described as normal (lasting between 4-6 days) in 45% of IBD patients (95% CI 31.13-59.66). Patients with UC were more likely to report regular menses than patients with CD. Eighty-six percent of participants reported no use of contraception. CONCLUSION: This is the first descriptive report of gynecologic conditions in which Puerto Rican patients with IBD have been studied. It is imperative to continue with similar larger studies to gain a broader idea of what are the gynecological needs of this population.

[Are we ready for the growing threat of virus dependent cervical cancer and the initiation of screening in conditions of insurance medicine?].

The dynamics is presented of the rates of virus dependent diseases, in particular cervical cancer (CC), which are directly connected with the level of organization of screening and subsequent treatment of cancer. It is shown that in conditions of insurance medicine a reduction of examination rooms and female enrollment in cytology screening is observed. As a result, over the past 5 years, CC incidence in the Novgorod region increased 1.2 times, and in Russia as a whole, the proportion of such cases in female population under 29 years since 2000 increased 4.5 times (from 2.0% to 9%). The urgent task of cancer control is to restore examination rooms, to overcome disagreements between government institutions and medical departments, to increase coverage of women by cytology screening by means of formation of the program of individual accounting of women.

Evolution of cervical cancer screening and prevention in United States and Canada: implications for public health practitioners and clinicians.

OBJECTIVE: Declines in cervical cancer incidence and mortality in Canada and in the United States have been widely attributed to the introduction of the Papanicolaou (Pap) test. This article reviews changes in screening and introduction of HPV vaccination. METHOD: Sentinel events in cervical cancer screening and primary prevention through HPV vaccination in the US and Canada are described. RESULTS: Despite commonalities, cervical cancer screening and prevention differ between the two countries. Canada has a combination of opportunistic and organized programs at the provincial and territorial level, while the US has opportunistic screening and vaccination systems. In the US, the HPV test along with the Pap test (co-testing) is part of national recommendations for routine cervical cancer screening for women age 30 and older. Co-testing is not being considered anywhere in Canada, but primary HPV testing is currently recommended (but not implemented) in one province in Canada. CONCLUSION: Many prevention strategies are available for cervical cancer. Continued public health efforts should focus on increasing vaccine coverage in the target age groups and cervical cancer screening for women at appropriate intervals. Ongoing evaluation will be needed to ensure appropriate use of health resources, as vaccinated women become eligible for screening.

Use of electronic medical record-based tools to improve compliance with cervical cancer screening guidelines: effect of an educational intervention on physicians' practice patterns.

OBJECTIVE: This study aimed to determine whether electronic medical record (EMR)-based tools influence providers' compliance with guidelines for cervical cancer screening in adolescent (<21 y) patients. MATERIALS AND METHODS: Three EMR-based tools to educate providers on cervical cancer screening guidelines were implemented midyear in 2010. Charts of adolescents with Pap and/or human papillomavirus results from January to December 2010 were reviewed. Physicians' demographic data were collected. Appropriateness of the index Pap and follow-up were determined using American Society for Colposcopy and Cervical Pathology guidelines. RESULTS: A total of 380 Pap tests were completed on 374 adolescents. Fewer Pap tests were done after the EMR interventions (229 vs 151, p < .0005). The proportion of Pap tests ordered by primary care providers was significantly higher than obstetrician-gynecologists (Ob/Gyns) (70% vs 30%, p < .0005). The number of Pap tests done by Ob/Gyns decreased 60% after EMR interventions (from 82 to 33, p < .0005) and that done by primary care physicians decreased 20% (from 147 to 118, p = .08). Indicated Pap tests were more often ordered by Ob/Gyn than by primary care, especially after EMR changes (31.4% vs 7.6%, p < .0005). Reflex human papillomavirus testing (if atypical squamous cells of undetermined significance) was high (74%) and did not improve after the EMR changes (72% vs 76%). The rate of co-testing in adolescents decreased in the primary care department after the EMR changes (13% vs 6%, p = .049). CONCLUSIONS: Electronic medical record prompts improved compliance with cervical cytology guidelines for adolescents, suggesting that EMR may be an important tool to enhance compliance with changing recommendations.

Primary care factors associated with cervical screening coverage in England.

BACKGROUND: The National Health Service Cervical Screening Programme was established to decrease the incidence and mortality of cervical cancer in England. METHODS: To identify socioeconomic and general practice factors associated with cervical screening coverage in England, a national cross-sectional study was conducted using data on 26 497 476 female patients registered with 7970 practices in 152 English primary care trusts (PCTs). The 2008-09 data on cervical screening coverage rates from the quality and outcomes framework (QOF) database were used with data on QOF indicators, staffing levels and socioeconomic status. RESULTS: The mean cervical screening coverage rate was 78.5% at the PCT level and 83.5% at the practice level. At both levels, cervical screening coverage was significantly negatively associated with the index of multiple deprivation score, percentage of female patients aged 25-49 years and percentage of ethnic minority patients. Also, at the practice level, the percentage of female patients aged 50-64 years, overall QOF score and records and information score were significantly positively associated with cervical screening coverage. CONCLUSIONS: Cervical screening coverage was significantly lower in PCTs and practices serving higher percentages of younger-aged women, non-Caucasian individuals and those living in socioeconomic deprivation. It is therefore important to adopt strategies to improve cervical screening coverage in these groups.

Immunomarkers in gynecologic cytology: the search for the ideal 'biomolecular Papanicolaou test'.

Harnessing the knowledge we have gained on the cell cycle disruption caused by human papillomaviruses (HPV) will likely lead to improved screening modalities for cervical cancer and its precursors. An easily applied biomarker that has high specificity and sensitivity would represent an attractive alternative or complement to cytology and HPV testing. To date, a number of promising markers have been investigated. These include p16(INK4A), MIB-1, BD-ProEx C, and L1. Newer possibilities involve a variety of gene products associated with aberrations of chromosome 3q, such as telomerase, p63, and PIK3CA, as well the combination of biomarkers such as p16(INK4A) and MIB-1 in the same assay. Although none of them has yet been incorporated into screening algorithms or found its way into routine practice, their performance characteristics remain a focus of current investigations. This review summarizes what we know and where we hope to go in translating basic pathobiology into clinical practice.

Gardnerella, Trichomonas and Candida in cervical smears of 58,904 immigrants participating in the Dutch national cervical screening program.

OBJECTIVE: To report the prevalence of Gardnerella, Trichomonas and Candida in the cervical smears of 9 immigrant groups participating in the Dutch national cervical screening program. STUDY DESIGN: Cervical smears were taken from 58,904 immigrant participants and 498,405 Dutch participants. As part of the routine screening process, all smears were screened for the overgrowth of Gardnerella (i.e. smears with an abundance of clue cells) and for the presence of Trichomonas and Candida. The smears were screened by 6 laboratories, all of which use the Dutch KOPAC coding system. The odds ratio and confidence interval were calculated for the 9 immigrant groups and compared to Dutch participants. RESULTS: Immigrants from Suriname, Turkey and the Dutch Antilles have a 2-5 times higher prevalence of Gardnerella and Trichomonas when compared to native Dutch women. Interestingly, the prevalence of Trichomonas in cervical smears of Moroccan immigrants is twice as high, yet the prevalence of Gardnerella is 3 times lower than in native Dutch women. CONCLUSIONS: Immigrants with a high prevalence of Gardnerella also have a high prevalence of Trichomonas. In the context of the increased risk of squamous abnormalities in smears with Gardnerella, such slides should be screened with extra care.

An audit of the cervical cancer screening histories of 246 women with carcinoma.

OBJECTIVE: Women with cervical carcinoma and residing in the Calgary Health Region between 1996 and 2001 were audited to characterize factors in the opportunistic cervical cancer screening pathway contributing to screening failures. MATERIALS AND METHODS: The cohort consisted of 246 women. Information on their Pap tests and colposcopic/gynecologic examinations was obtained from the files of Calgary Laboratory Services and their colposcopic/cancer center treatment charts. Screening failure factors were defined, and frequencies were calculated. RESULTS: Screening failure factors were as follows: (1) 41 (16.7%) were not screened, that is, no Pap test screening; (2) 29 (11.8%) were underscreened, that is, no Pap test within 12 months of diagnosis; (3) 28 (13.7%) were undersampled, that is, the Pap test result was negative; (4) 34 (13.8%) had no referral for a colposcopy/gynecology examination, and/or it was delayed for more than 3 months; (5) 18 (13.2%) had delayed referral for examination of an atypical glandular cell-high-grade squamous intraepithelial lesion and higher Pap test for more than 3 months; and (6) 73 (55.3%) were underdiagnosed, that is, the diagnosis in colposcopy examination was less than malignant. Underreported Pap tests and delayed Pap test reporting could not be fully investigated, but limited evidence suggested that underreporting contributed to some failures. CONCLUSIONS: Factors other than recruitment to cytological screening need targeted improvement if the region's cervical cancer prevention program is to be more effective.

Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre.

OBJECTIVES: To examine temporal trends in the use of vault cytology tests in primary and secondary care and the demographics of those women tested. METHODS: Retrospective analysis of routinely collected data concerning women who had a vault cytology test processed during a 10-year period (1 April 1995 to 31 March 2005) at Birmingham Women's NHS Foundation Trust. RESULTS: A total of 8457 vault cytology tests from 3164 women (range 1-17 tests, median = 2) were processed, representing approximately 2% of the cervical cytology workload of the Department of Cytopathology at Birmingham Women's Hospital. There was a significant reduction in annual numbers processed (Pearson correlation -0.958, P < 0.001). Significant abnormalities (mild dyskaryosis or worse) were detected in 4.5%, with malignancy being detected in <0.1%. The unsatisfactory cytology test rate was 10.7% overall. There was a reduction in the numbers of vault cytology tests coming from the community, hospital outpatient clinics and operating theatres over time (χ(2) for linear trend = 139.53, 9 d.f., P < 0.0001). Tests originating from community settings had the lowest disease detection rates: no malignancies and only two severe abnormalities were detected from almost 4000 primary care samples; abnormal results represented 2.8% (n = 113), of which the majority (n = 73) were borderline results. All cancers (n = 8) were detected in samples taken in gynaecology and colposcopy clinics. CONCLUSIONS: Vault cytology test usage appears to be reducing, particularly from outpatient clinics and primary care. Community detection rates are very low. Further research is required to establish the true costs and benefits of vaginal vault cytology.

Google search volume trends for cancer screening terms during the COVID-19 pandemic.

The COVID-19 pandemic has led to delays in cancer diagnosis, in part due to postponement of cancer screening. We used Google Trends data to assess public attention to cancer screening during the first peak of the COVID-19 pandemic. Search volume for terms related to established cancer screening tests ("colonoscopy," "mammogram," "lung cancer screening," and "pap smear") showed a marked decrease of up to 76% compared to the pre-pandemic period, a significantly greater drop than for search volume for terms denoting common chronic diseases. Maintaining awareness of cancer screening during future public health crises may decrease delays in cancer diagnosis.

Increasing Vaginal Chlamydia Trachomatis Testing in Adolescent and Young Adults.

OBJECTIVE: The Centers for Disease Control and Prevention recommend testing for Chlamydia trachomatis in sexually active female patients <25 years old using nucleic-acid amplification tests (NAAT) from a vaginal swab. Our providers were typically testing using the less sensitive urine NAATs. We aimed to increase the percentage of urogenital C trachomatis NAATs performed by using vaginal swabs in adolescent female patients ages 10 through 20 years from 1.4% to 25%. METHODS: We implemented 3 interventions at 3 pediatric practices over 12 months including education, process standardization, and cross-training. We used statistical process control to analyze the effect of interventions on our primary outcome: the percentage of urogenital C trachomatis tests performed with a vaginal swab. Our balance measure was the total number of urogenital C trachomatis tests. RESULTS: There were 818 urogenital C trachomatis tests performed: 289 before and 529 after the first intervention. Of urogenital C trachomatis tests in the preintervention time period, 1.4% were performed by using vaginal swabs. We surpassed our aim of 25% 6 weeks after the first intervention. We noted sustained improvement after the second intervention, with an average of 68.3% of tests performed by using vaginal swabs for the remaining postintervention period. There was no difference in the overall number of urogenital C trachomatis tests pre- and postintervention. CONCLUSIONS: Using quality improvement methodology and implementing easily replicable interventions, we significantly and sustainably increased use of vaginal swabs. The interventions standardizing processes were associated with a higher impact than the educational intervention.

[Cervical cancer screening: past--present--future]. / Zervixkarzinom-Screening: Gestern--heute--morgen.

Despite the undisputed and impressive success which has been achieved since the 1960s by cervical cytology in the fight against cervical cancer and its precursor stages, during which the mortality rate in industrialized countries over the last 40 years has been reduced by two-thirds to three-quarters, a perfect and error-free screening procedure is still a long way off and will probably never be reached. There are two main reasons for this, the lack of adequate coverage and suboptimal quality and assessment of smears. Two screening procedures are in use Europe, an opportunistic and an organized system. Both systems have many advantages but also disadvantages. In organized programs the coverage is higher (up to 80%), although similar numbers are also achieved by non-organized programs over a 3-year cycle, even if they cannot be so exactly documented. The decision on which system is used depends on the health system of the country, public or non-public, and many other national circumstances. However, in both systems prerequisites for a satisfactory result is a high quality in the sampling technique, the processing and the assessment. Therefore, several guidelines have been introduced by state and medical societies for internal and external quality assurance. New technologies, such as thin-layer cytology or automation for replacement or support of conventional cytology liquid-based cytology proved not to be superior enough to justify the high costs of these systems. The recognition of the strong causal relationship between persistent infection with high-risk human papillomavirus (HPV) types and cervical cancer and its precursors has resulted in the development of comparably simple tests. Primary screening using HPV typing alone is not recommended in opportunistic screening due to the low specificity but high sensitivity because it leads to many clinically irrelevant results which place women under stress. In organized screening HPV testing is always and only possible in combination with cytology. Various models and approaches are in the testing phase and appear promising. HPV testing is on the other hand well accepted and recommended as a triage test to select women with equivocal smear results (Pap group III, ASCUS) if a biopsy is required or can be followed up and also for follow-up of patients after cone biopsy. However, vaccination of young girls against oncogenic HPV types which has now become widespread still leaves many questions open for the future because the observation period is too short. There is justified hope that this will become a valuable tool in cervical cancer control and may lead to a substantial reduction in the burden of cervical cancer in the future. However, as the current vaccines on the market do not cover all oncogenic virus types and the effects of vaccination will only be observed after many years, the necessity of a cytological screening will remain unrestricted. Therefore, cervical cytology will remain as the trusted, simple to use, economic and proven, like no other method for early cancer detection, efficient procedure even in the foreseeable future. If carried out with the highest quality demands it will play a central role in the early detection of cervical cancer.