Forty years of repeated screening: the significance of carcinoma in situ.

Two cohorts of women born in 1914-18 and 1929-33 who participated in a cervical screening programme have been followed for over 40 years. Age-specific incidence rates of squamous carcinoma of the cervix by rank of smear and length of interval between smears are reported. The younger cohort, who had undergone more frequent screening, had lower rates of invasive disease. From these incidence rates, estimates of false-negative rates and regression rates for carcinoma in situ have been made. The false-negative rate was estimated to be about 15%. Regression seemed more frequent in younger than in older women. For the younger cohort it was estimated to be 72% and in the older 47%. A comparison of the rates of in situ carcinoma with those of invasive disease suggests that the screening of the younger cohort reduced the rate of invasive disease to at least one-half or one-third of what it would have been if screening had commenced later. Rates of disease appear less dependent on age than previously thought and are consistent with causation by an infective agent.

Self-esteem, anxiety, and loneliness in preadolescent girls who have experienced sexual abuse.

This study sought to clarify and extend existing knowledge of the negative sequelae of sexual abuse by comparing levels of self-esteem, anxiety, and loneliness in abused and nonabused girls. Comparisons indicated that sexually abused children had lower levels of self-esteem than nonabused children, but that levels of anxiety and loneliness did not differ between the groups. These findings empirically confirm one of the sequelae of sexual abuse commonly cited in the clinical literature and point to the need for interventions designed to redress this adverse effect.

Cervical intraepithelial neoplasia in female prisoners in British Columbia.

The annual incidence rates of cervical intraepithelial neoplasia (CIN), grades I to III, from 1975 to 1983 among 2440 prisoners in British Columbia for whom a history of screening by means of the Papanicolaou test was available were two to three times higher than the expected rates in the general female population of British Columbia. The rates among the prisoners from 1970 to 1984, although small, increased with a trend similar to that in the general population. Despite increases in the general population we conclude that prisoners are still at high risk for CIN.

Organisation and results of the cervical cytology screening programme in British Columbia, 1955-85.

A screening programme to detect preinvasive carcinoma of the cervix was started in British Columbia in 1949. Since 1970 the number of women who have been screened at least once has been maintained at about 85% of the population at risk. More than 500,000 cervical smears are being examined each year in the central laboratory. There has been an appreciable increase in the number of cases and rates of carcinoma in situ seen since 1970, particularly in women between 20 and 30 years of age. Since the programme started over 26,000 cases of squamous carcinoma in situ have been detected and treated. The incidence of clinically invasive squamous carcinoma of the cervix has fallen by 78% during the period under review, and mortality from squamous carcinoma of the cervix has fallen by 72%. A colposcopy programme, introduced throughout British Columbia over the past 12 years, has been important in reducing the problems of managing preinvasive lesions, particularly in younger women. It is concluded that the reduction in morbidity and mortality from invasive squamous cancer of the cervix in British Columbia over the past 30 years is directly attributable to the province wide screening programme and that a large potential increase in invasive cervical cancer rates among younger women is being prevented.

Colposcopic accuracy in the diagnosis of microinvasive and occult invasive carcinoma of the cervix.

One hundred eighty patients with microinvasive and occult invasive squamous cell carcinoma of the cervix who were examined by colposcopy during a ten-year period are reviewed. Forty-two percent of patients with microinvasive carcinoma and 28% of patients with occult invasive carcinoma had an unsatisfactory colposcopic examination. Colposcopy led to the correct management in 90% of patients with occult invasive cancer and in 84% of patients with microinvasive carcinoma. Colposcopy appeared to be less sensitive in detecting microinvasive lesions than in detecting occult carcinoma. Two-thirds of the errors made were colposcopist-related, either failure of interpretation or protocol violation. A small but definite group of patients will have lesions whose colposcopic appearance is not sufficiently distinct or characteristic to permit a diagnosis of early invasion.

Radiation treatment of carcinoma of the vulva, 1950-1980.

A retrospective study of all patients with carcinoma of the vulva treated by radiation therapy at the A. Maxwell Evans Clinic of the Cancer Control Agency of British Columbia, between 1950 and 1980, is reported. Sixty-eight patients, representing 30% of all referred patients with vulvar cancer, were analyzed for survival, recurrence patterns, complications, and clinical features. This group is companion to a series of patients treated with operation reported in 1979. The data confirm a major role for radiation therapy both in palliation and in combined radiotherapy-operation. For 13 cases, radiotherapy with curative intent was used in combination with operation resulting in a 5-year actuarial survival of 92%, with acceptable posttreatment morbidity. The advantages of preoperative radiotherapy, particularly for posterior vulvar lesions, are suggested by the data, and the need for a reappraisal of the role of radiotherapy in vulvar carcinoma is stressed.

Ovarian carcinoma: a multivariate analysis of prognostic factors.

Five hundred and fifty six women with invasive epithelial ovarian carcinoma were assessed for postoperative treatment between 1966 and 1976. The records of this group were reviewed retrospectively. Sixteen characteristics of the patient and tumor were analyzed for prognostic significance by univariate and multivariate techniques. Tumor grade, the presence of residual disease, and patient performance status are identified as stage-specific independent prognostic factors. These independent factors define patient subsets with good, intermediate, and poor prognosis within each stage. The results show that more effective treatment strategies are required for patients in poor prognosis subsets. Estimates of tumor grade, extent of residual disease, and performance status should be included in reports of treatment outcome.

Primary invasive carcinoma of the vagina.

Data are presented from 97 patients treated for invasive primary epithelial carcinoma of the vagina between 1950 and 1980. The disease is primarily one of the elderly as 63% were found to be older than 60 years of age. Eleven of the 97 patients either refused or were unable to complete treatment because of poor medical condition or advanced stage of disease. Combined external and intracavitary radiation was the most common form of treatment. The overall two-year survival rate was 47%, or 59% when corrected for deaths due to other causes. Patients with stages I and II disease had corrected survival rates of 75% and 68%, respectively. Our results indicate that stage of disease is the most significant prognostic factor. Optimal results will be obtained with early diagnosis and individualized treatment.

The current status of screening for uterine cancer.

The screening program for cervix cancer in the Province of British Columbia appears to have reached a stable state. It has achieved a reduction in incidence of clinical squamous carcinoma in women over 20 of about 75% and reduction in mortality of about two thirds. Data has been presented to suggest that no further improvement in these rates should be forthcoming in a voluntary program such as ours. There has been a real increase in the numbers of in situ carcinomas found in our population but despite this increase clinical invasive carcinoma has not risen and we attribute this to the success of the program in intercepting disease before it becomes invasive. Endometrial carcinoma has not increased in our population and we do not feel that the current methods for early detection of this disease are applicable to a province-wide study. We intend to continue to emphasize the earliest possible investigation of abnormal peri- and postmenopausal bleeding by fractional curettage, as our mainstay of detection.

The value of a Pap smear program and suggestions for its implementation.

The cervical cancer screening program in the Province of British Columbia has been operating since 1949. In the opinion of the author, it has contributed substantially to the reduction in incidence and mortality of clinical squamous carcinoma of the cervix. The data base of the program has allowed the author to observe changes in the age-specific rates of preclinical carcinoma. The author has also been able to make some observations about the periodicity of Pap smear examinations. The organization of the colposcopy program in the province are discussed as is the effect of this new treatment on the data resulting from the program.

Combination v. sequential therapy with melphalan, 5-fluorouracil and methotrexate for advanced ovarian cancer.

The results of a national clinical trial to compare combination and sequential chemotherapy for stage III or IV ovarian cancer are reported. Of the 253 patients from 16 centres across Canada who were admitted to the trial 13 were excluded from the analysis. All the patients were observed for 2 to 5 years from entry into the trial. There were no differences in response to therapy or in survival between the patients treated with melphalan followed by 5-fluorouracil and then by methotrexate in high dosage and the patients treated with the same agents in combination. Patients with minimal residual disease after resection of stage III ovarian cancer had a good prognosis. Other favourable prognostic factors were age (less than 55 years), performance status (90% or 100% on the Karnofsky scale) and histologic grade of the tumour.

Radical hysterectomy in the treatment of cervical cancer.

Two hundred and forty-one patients were treated with radical hysterectomy at our institution between 1949 and December, 1978. The corrected 5-year survival rate for all patients with squamous cell carcinoma of the cervix was 73%. Seventeen percent of patients with occult invasive carcinoma had positive lymph nodes at the time of operation. The corrected 5-year survival rate for patients with Stage IB carcinoma who had positive nodes was 66%. Operations for recurrent or persistent disease after radiotherapy resulted in a 5-year survival rate of 54%. Current indications for radical hysterectomy and lymphadenectomy at our center are discussed.

PIP: This study reports the center's experience (Cancer Control Agency of British Columbia or CCABC and the Vancouver General Hospital) with 241 patients (aged 20 to 71+) who had undergone radical hysterectomy for invasive cancer during the period 1949 through 1978, and how this experience has led to the center's current indications for use of such surgical procedural procedure. Approximately 50% of the patients were aged 40 years or less, and 2/3 were under the age of 51; this suggests that most patients have long life expectancy if they could be cured of their disease. All but 15 patients had primary cervical carcinoma (Table 2). 76% of the patients had squamous cell carcinoma of the cervix. Of the 226 cervical cancers, 81.9% were squamous cell and 12.4% were adenocarcinoma. 5.6% had a mixed adenosquamous carcinoma. Diagnosis of cervical cancer correlated closely with the presence or absence of lymph node involvement at time of operation. Tables were also provided to present data on 5-year survival rates of patients with positive lymph nodes and squamous cell carcinoma; various treatment methods and results by stage for the 137 patients with squamous cell carcinoma of the cervix; 10, 15 and 20 year survival rates by stage for patients with squamous cell carcinoma; postoperative complications in 241 patients, and effect of radiotherapy on rate of development of fistulas. The data shows that radical hysterectomy was not a commonly performed procedure in this institution during the past 3 decades, and the encouraging 52% survival rate for patients managed with radical hysterectomy for recurrence or persistence of cancer after radiotherapy indicates the need for frequent, careful follow-up of patients with early stages of cancer. Current indications for radical hysterectomy and lymphadenectomy at CCABC are discussed.