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.

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.

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.

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.

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.

Prevalence of cervical cancer and pre-cancerous lesions among unscreened Women in Kumasi, Ghana.

Ghana does not have a universal population-based cervical cancer screening program and there is very limited information about the distribution of cervical epithelial cell lesions. This study provides evidence that a moderately high prevalence of cervical cancer and precancerous lesions exists among unscreened women in Kumasi.The prevalence of cervical epithelial cell abnormalities among a cross-section of women attending cervical cancer screening for the first time in a suburb of Ghana from 2011 to 2014 was studied. Cervical smears were prepared and examined independently by 2 cytotechnologists and confirmed by a pathologist. Cervical lesions were classified according to the Bethesda System for cervical cytology 2001.Out of the 592 women for whom a Pap smear was available for evaluation, 555 (93.8%) were negative for intraepithelial lesion or malignancy. Eight women (1.4%) showed atypical squamous cells of undetermined significance (ASCUS), 9 (1.4%) low-grade squamous intraepithelial lesions, and 2 (0.3%) high-grade squamous intraepithelial lesions. A total of 15 (2.5%) smears were unsatisfactory for cervical cytology. Additionally, 3 women (0.5%) had squamous cell carcinoma, giving an overall rate of 3.7% for epithelial cell abnormalities.Cervical cancer and precursor epithelial cell abnormalities are common among women in Kumasi for a disease that can be prevented by early detection through routine screening and management. This study provides adequate background data to recommend the implementation of cervical cancer screening in all eligible women in Ghana.

Updates in Cervical Cytology: The 90-Year-Long Journey from Battle Creek to Today.

Ninety years ago, at the Battle Creek conference, Papanicolaou introduced cervical exfoliative cytology. Since then, the "Pap test" has come a long way. The discovery of a causal relationship between cervical carcinoma and HPV infection opened the door for molecular testing and immunomarkers for HPV. The Clinical Laboratory Improvement Amendments, 1988, established quality assurance and quality control programs to monitor performance of cytology laboratories. The Bethesda System for reporting cervical cytology laid the foundations for cervical cytology education, implementation of management guidelines, and further research on cervical carcinogenesis. HPV vaccine penetration in both genders remains 62% or less.

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.

Establishment of a national cervical screening programme in Ireland, CervicalCheck: the first 6 years.

The national cervical screening programme, CervicalCheck, commenced in Ireland in 2008. Free cervical smear tests are offered to over 1.2 million women aged 25-60 every 3 (aged 25-44) and 5 (aged 45-60) years. The purpose of this paper is to highlight the achievements and document the experience of the first 6 years of a new cervical screening programme. Data were extracted from the programme screening register and colposcopy management systems. SAS, version 9.4 was used for statistical analysis. Over 1.98 million smear tests were performed in over 1 million women during the first 6 years of the programme. Overall 5-year coverage at the end of the sixth year was 77.0%, where coverage is presented for the target population of women aged 25-60 years and is adjusted for hysterectomy rates. The numbers of women attending colposcopy increased significantly from 10 000 new patients attending for the first time in the first year to a peak of almost 17 500 in the third year. Increased capacity in colposcopy has delivered significant improvements in waiting times; the percentage of women referred to colposcopy offered an appointment within 8 weeks increased from 41.5% in year 1 to 93.4% in year 4 and has remained above the greater than 90% standard thereafter. The number of biopsies increased markedly, with 33 768 women being diagnosed with cervical intraepithelial neoplasia-grade 2 (CIN2), CIN3 or adenocarcinoma in situ and 860 being diagnosed with invasive cancer by the end of the sixth year. Lessons from CervicalCheck include the importance of capacity planning in programme delivery. The programme continues to evolve, particularly with the increased usage of human papillomavirus testing and planning for future testing of the human papillomavirus (HPV)-vaccinated cohort.

Trends in Pap test practices and results: An 11-year review of the annual ACHA Pap Test and STI Survey.

OBJECTIVE: To conduct a trend analysis of Pap test practices, Pap test results and related women's services and guidelines of college health centers. PARTICIPANTS: College health centers who participated in the annual ACHA Pap Test and STI (sexually transmitted infection) Survey years 2004-2014 (n ranged from 127 to 181 depending on year). METHODS: Descriptive analyses are presented with ANOVAs (Analysis of Variance) and chi-square tests calculated to examine trends over time. RESULTS: The number of Pap tests significantly decreased over time; however, the percentage of normal and HSIL (high-grade squamous intraepithelial lesion) results did not vary. Availability of conventional cytology slides and cryotherapy were significantly associated with year. Over time, college health centers' guidelines related to initiation of Pap testing evolved to consistently conform to national recommendations for cervical screening. CONCLUSIONS: The results indicate most college health centers are following the current national guidelines regarding Pap testing for young adult women.

Changing Trends and Practices in Cytopathology.

OBJECTIVE: To explore the current and anticipated changes in the practice of cytopathology. STUDY DESIGN: The present review is based on a review of recent literature and an evaluation of the authors' personal experiences. RESULTS AND CONCLUSION: In recent years the practice of cytopathology, nationwide and in our institute, has witnessed a major change affecting gynecologic and nongynecologic cytology. There has been a decline in the number of Papanicolaou tests which has affected the utilization of cytotechnologists and provoked a reorganization of their work flow. The "need to do more with less" in the era of targeted therapy/personalized medicine has resulted in an increasing preference for needle core biopsy when performing a rapid on-site evaluation. We feel that this change is unavoidable. It is pertinent that cytopathologists as a group recognize this change and prepare themselves and the trainees not only to become adapt but also to use this as an opportunity to discover the yet unexplored world of cytology.

Federal Support for Family Planning Clinics Associated with Dramatic Gains in Cervical Cancer Screening.

BACKGROUND: Since the 1990s, policymakers have successfully increased cervical cancer screening through federal and state public policies. However, the most dramatic gains in Pap smear use occurred in the 1960's and 70's, during the establishment of federal support for family planning clinics through the War on Poverty and Title X. This study estimated the effect of this support on cervical cancer screening, and quantified its role in dramatic increases in Pap smear use. METHODS: Using a natural experiment in the timing and receipt of federal family planning grants, the screening behavior of women who did and did not have access to a federally funded family planning clinic were analyzed. Cross-sectional probability models of annual and lifetime Pap smear use using the 1970 National Fertility Survey were estimated and linked to administrative data on grant timing and receipt between 1964 and 1973. FINDINGS: Federal support for family planning clinics was associated with a 7-percentage point increase in annual use (p < .01), and a 5-percentage point decrease in never use of the Pap smear (p < .001). Scaled by the fraction of women who used funded clinics, federal support for family planning was associated with a roughly 70% increase in Pap smear use. Estimates suggest that the establishment of federal support could explain as much as 15% of the national increase in Pap smear use between 1966 and 1973. CONCLUSIONS: Federal support for family planning played an important--and previously unacknowledged--role in promoting cervical cancer screening and investments in future health.

Trends in Cervical Cytology Screening and Reporting Practices: Results From the College of American Pathologists 2011 PAP Education Supplemental Questionnaire.

CONTEXT: The College of American Pathologists periodically surveys laboratories to determine changes in cytopathology practices. We report the results of a 2011 gynecologic cytology survey. OBJECTIVE: To provide a cross-sectional survey of gynecologic cytology practices in 2010. DESIGN: In 2011, a survey was sent to 1604 laboratories participating in the College of American Pathologists gynecologic cytology interlaboratory comparison education program and proficiency testing programs requesting data from 2010 on the following topics: terminology/reporting, cytotechnologist workload, quality assurance, reagents, and ancillary testing. RESULTS: Six hundred and twenty-five laboratories (39%) replied to the survey. The nonstandard use of "low-grade squamous intraepithelial lesion cannot exclude high-grade squamous intraepithelial lesion" is used by most laboratories to report the presence of low-grade squamous intraepithelial lesion with possibility of high-grade squamous intraepithelial lesion. Most laboratories also report the presence or absence of cells from the transformation zone. Most respondents do not limit cytotechnologist screening workload during the work shift. Only about one-third of laboratories (188 of 582; 32%) use image-assisted screening devices. Rapid prescreening as a quality assurance measure is used by only 3.5% (21 of 594) of the laboratories. When used for screening, most laboratories use the imager for retrospective review of slides to detect human locator and interpretive errors. Most laboratories receive both liquid-based cytology samples (mainly ThinPrep, Hologic, Marlborough, Massachusetts) and conventional Papanicolaou tests. Expiration dates of liquid-based cytology test vials are not usually recorded. CONCLUSIONS: The field of gynecologic cytology is evolving rapidly. These survey results offer a snapshot of national gynecologic cytology practices in 2010.

Age Specific Cytological Abnormalities in Women Screened for Cervical Cancer in the Emirate of Abu Dhabi.

BACKGROUND: Cervical cancer is the second most common cancer in women worldwide, with about 500,000 new cases and 270,000 deaths each year. Globally, it is estimated that over one million women currently have cervical cancer, most of whom have not been diagnosed, or have no access to treatment that could cure them or prolong their lives. In the United Arab Emirates (UAE) cervical cancer is the third most common cancer in women. MATERIALS AND METHODS: A population-based cross-sectional retrospective survey of cervical smear abnormalities was conducted in the Emirate of Abu Dhabi, UAE, from January 2013 to December 2013 by collecting consecutive liquid-based cytology samples from the Department of Pathology at the SKMC Hospital in Abu Dhabi city. RESULTS: The total number of women screened for cervical cancer for the year 2013 at SKMC was 4,593, with 225 (4.89%) abnormal smears. The majority of the abnormal smear results were atypical squamous cells of undetermined significance (ASCUS) 114 (2.48%). This study showed 60% increase in the rate of abnormal cervical smears in the UAE over the last 10 years. In this study the highest incidence of high grade abnormalities were seen in women above the age of 61 years (1.73%), this might be due to the fact that this group of women missed the chance of screening of cervical cancer earlier in their lives or could be explained by the well-known second peak of HPV infection seen in many prevalence studies. CONCLUSIONS: We conclude that the rate of abnormal cervical smear in the screened Abu Dhabi women is not different from the rate in developed countries. A notable increase in both low and high grade abnormalities has occurred within the last decade.

Pap Test Reporting Rates for Conventional Smear and Liquid-Based Cervical Cytology from the Largest Academic Women's Hospital in China: Analysis of 1,248,785 Pap Test Reports.

OBJECTIVE: The Obstetrics and Gynecology Hospital of Fudan University (OGHFU) in Shanghai is the largest academic women's hospital in China. Between 2009 and 2014, the use of liquid-based cytology (LBC) significantly increased while gradually adopting the Bethesda System (TBS), and in 2012 local regulations mandated that pathologists replace technicians to sign out Pap tests. DESIGN: A retrospective OGHFU database search documented all Pap test reports between 2009 and 2014 by specimen type, either LBC or conventional Pap smears (CPS), and final reporting category. A total of 1,224,785 Pap reports were analyzed to document variations in Pap test reporting during a period of major change in cervical screening in China. RESULTS: LBC gradually replaced CPS, which declined from over 65% of Pap tests in 2010 to 6.4% in 2014. Of 514,811 Pap reports using the traditional class system, class I (negative) reports accounted for 98.3% of results. With the introduction of TBS reporting, pathologist reviews and substantial replacement of CPS by LBC, the laboratory abnormal Pap test rate increased significantly to almost 5%. CONCLUSIONS: Changes in cervical cytology reporting between 2009 and 2014 in China's largest academic women's hospital reflected both increased use of LBC and the introduction of pathologist TBS reporting. Abnormality rates increased significantly and fell within CAP benchmark ranges.

El futuro de la citología cérvico-vaginal / The future of cervico-vaginal cytology

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