"Gynaecological cancer screening" or "cervical screening?" The case of Hungary.

In Hungary, "gynaecological cancer screening" by gynaecologists having interest in oncology has had a long history. The screening tool was colposcopy alone embedded in complete gynaecological examination. Later on smear-taking for cytology has been added. This screening protocol has survived until now both in the gynaecological community and public. In the meantime, as it proved its ef- fectiveness, cytological examination has been internationally recommended,\ as sole method of organized cervical screening; in case of non-negative test result, gynaecological examination including colposcopy is justified. Smear-taking can be undertaken by trained paramedical personnel. The authors have made an attempt to argue the use of "cervical screening" instead of "gynaecological cancer screening", which is deeply entrenched into both professional and public consciousness in Hungary.

Cervical screening in Hungary: why does the "English model" work but the "Hungarian model" does not?

A comparison has been made between the English practice and the "Hungarian model" of cervical screening. In England, until 1986, extensive opportunistic screening was the practice, but--as it had no effect on cervical cancer mortality--afterwards, the screening policy was changed to be strictly in line with international recommendations. On the other hand, in Hungary, the "old practice" has been petrified: gynaecologists are the "gatekeepers", a "gynaecological examination completed with smear-taking for cytology" makes up the screening strategy. Although in the frame of a National Public Health Programme all the prerequisites for nationwide organised screening have been provided, and an up-to-date screening strategy declared, 20-times as many smears are taken and analysed outside as inside the programme, and the efforts have had no impact on cervical cancer mortality. This is because "old habits die hard". There is an urgent need to reconsider the screening strategy, and to reorganise the cervical screening practice in Hungary.

The organisation and results of first screening round of the Hungarian nationwide organised breast cancer screening programme.

BACKGROUND: The aim of this paper is to give an overview of organisational issues of the Hungarian nationwide organised breast cancer screening programme and to provide the results of the first screening round of the programme for the years 2002-2003. PATIENTS AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration covering the period 2000-2003. Women who underwent mammography screening were included into the study. RESULTS: Uptake of the organised screening programme in 2002-2003 was 45.09%, while the recall rate was 7.23%. Malignant cases represented 65.38% of total surgeries and 0.36% of total number of screened women yielding a cancer detection rate 3.6 per 1000 screened women. Malignant cases of 10.78% were identified as ductal carcinoma in situ, while 89.22% was invasive cancer. Benign to malignant ratio was 0.54 : 1. CONCLUSION: There is therefore an urgent need to closely monitor performance and to review programme policies and procedures with the aim of increasing both the participation rate and the proportion of women eligible to attend screening.

[Morphological parameters of breast cancers detected by mammography with and without organized screening; a comparative study]. / Mammográfiával felismert rákok morphologiai paramétereinek összehasonlítása a területileg szervezett szürés során és alkalomszerüen vizsgáltaknál.

Some pathological findings and prognostic indices recorded in breast cancer cases, detected, on one hand, by a provider-initiated mammography screening program (Group 1), and, opportunistically, in self-referred symptomatic women (Group 2) on the other, are compared. In 8877 symptom-free women, aged 50-65 years, individually invited to attend the screening offered for the residents of the III., XII. and XIII. districts of Budapest, 67 cancer cases were detected (7.5 in 1000 screenees), in accordance with the cancer detection rate of the first, "prevalence" round of organised screening programmes. In the other group of 1593 symptomatic, self-referred women of the same age, 113 cancer cases were diagnosed by mammography. As far as the pathological parameters are concerned, the number of cases with invasive cancer less than 15 mm in diameter, and those with axillary nodes present was found to be significantly higher in the screened group as compared to the self-referred one (p < 0.01). In "small" cancers (i.e. less than 15 mm in diameter), no significant difference was found in the proportion of histologic grade III tumours among the two groups. In screen-detected cancers both the morphometric prognostic index (as calculated by Baak et al.) and the Nottingham Prognostic Index (NPI) proved to be more favourable, as compared to those in the self-referred group. The p-value as determined by Mann-Whithey test was 0.000003 in the screened group, and 0.000015 in the other one. These findings provide convincing evidence in support of the public health importance of provider-initiated, organised mammography screening for breast cancer, therefore, the introduction on service basis of organised breast screening into the health care system in Hungary is strongly recommended by the authors.

[Cancer screening in Hungary: World Bank supported model programs]. / Rákszúrés magyarországon: modellprogramok világbanki támogatással.

Since 1995, a model cancer screening program has been in operation in Hungary, the overall purpose of which is to promote the establishment of effective and efficient screening programs by means of adapting the internationally agreed principles of organized screening to the needs and opportunities in Hungary. The establishment and operation of a national population-based cancer registration system is an other aim of the Program. The model program--financed partly from a loan from the World Bank, partly from local funds provided by the Government of Hungary--is to develop standard procedure for cervical, breast and colorectal screening and to end up with tested recommendations for introduction of organized screening of proved effectiveness, integrated into the health care system, on country-wide service bases in Hungary.

WHO initiative: cancer prevention in Europe.

In recent years, the countries of central and eastern Europe, the Baltic States, and the newly-independent countries (established in place of the former Soviet Union), have experienced a much heavier burden of cancer as compared to other subregions of Europe. This appears to be the result of a decline in the standard of health care services, environmental neglect and the high prevalence of health-damaging behaviour, smoking in particular. Their anti-cancer potential falls short of their needs. The existing and still widening gap between what are considered best and worst patterns, practices and prospects in cancer control in Europe has posed a challenge to both the World Health Organization (WHO) and the international cancer community. On WHOs initiative, a group of major European cancer organizations is determined to use their considerable potential, both moral and scientific, in supporting national efforts in all possible ways in those countries that need progress. Recently, WHO has initiated an all-European alliance with the intention of narrowing the gap between what are regarded as best and worst patterns, practices and prospects in cancer control in Europe.

[Use of aspiration biopsy for the cytodiagnosis of non-Hodgkin's lymphoma]. / Vozmozhnosti primeneniia aspiratsionnoi biopsii dlia tsitodiagnostiki nekhodzhkinskikh limfom.

The data on application of fine-needle aspiration biopsy followed by cytologic investigation in the diagnosis of non-Hodgkin's lymphomas are reported. Changes in cell population and presence of proliferating cells, characteristic of non-Hodgkin's lymphomas, can be detected by this method. Since the procedure is simple, painless, complication-free and assures a more than 90% accuracy, its application is indicated for diagnosis of non-Hodgkin's lymphomas.

A correlation between cell surface sialyltransferase, sialic acid, and glycosidase activities and the implantability of B16 murine melanoma.

A murine melanoma variant (B16-F10ir6), resistant to lymphocytic cytolysis, has been shown previously to produce lower numbers of tumor nodules in the lung of C57BL/6J mice following i.v. inoculations. These differences found in tumor implantation and lymphocyte recognition may be due to changes in surface properties of this cell line. Therefore, membrane-bound sialic acid (released by Vibrio cholerae neuraminidase treatment), ectosialyltransferase activity, and total cellular glycosidase levels were measured in this cell line and compared with levels in its parent melanoma tumor cell line, B16-F10, which was selected for its enhanced ability to form tumor nodules. The results of these studies indicate a correlation between the degree of lung implantation and the amount of tumor cell sialic acid accessible to neuraminidase cleavage, tumor cell surface sialyltransferase activity, and several cellular glycosidase activities. These results are consistent with the idea that membrane structural changes in the glycocalyx may account for the ability of a tumor cell to implant and metastasize.

Elevation of lysosomal enzymes in primary Lewis lung tumor correlated with the initiation of metastasis.

Lysosomal enzymes were elevated about two-fold in primary s.c. Lewis lung carcinoma as compared with metastatic nodules in the lung. In a time course experiment, a general two-fold elevation of acid phosphatase and several glycosidases was observed in the primary tumor between the 14th and 17th postimplant day following s.c. inoculation of Lewis lung carcinoma. This increase in hydrolytic enzyme activity was not due to necrosis in the primary tumor since a comparison of enzyme activities in the nonnecrotic and necrotic areas demonstrated much higher activities in the nonnecrotic areas. No increases in lysosomal enzyme activity were observed with time in Sarcoma 180, a tumor which does not metastasize. There was no change with time in primary Lewis lung tumor lactate dehydrogenase activity while a 7-fold increase in serum lactate dehydrogenase activity was observed in tumor-bearing mice. Mitochondrial succinate-2-(p-iodophenyl)-3-(p-nitrophenyl)-5-phenyltetrazolium reductase levels fell in the primary Lewis lung tumor as the tumor size increased. A positive correlation was observed between the time of the elevations of tumor lysosomal enzymes in Lewis lung carcinoma and the appearance of micro- and macrometastatic lesions in the lungs. The mechanisms accounting for the increased intratumoral lysosomal enzymes are unknown, but they may be related to macrophage infiltration or other tumor-host interactions which may facilitate the dissemination of tumor cells.

Fine-needle biopsy of thyroid gland.

Critical analysis is provided by the authors on cytologic examination combined with histology of 131 patients with thyroid alterations. Cytologic examination yielded seven false-negative and four false-positive findings. Sensitivity of the procedure was 0.78 and the specificity 0.97. Aspiration cytology of the thyroid gland combined with other methods of examination can be considered an advance in the diagnostics of thyroid diseases.

[Aspiration cytodiagnosis of breast tumors]. / Aspiratsionnaia tsitodiagnostika opukholei molochnoi zhelezy.

Aspiration biopsy cytology was employed by the authors in 250 cases for pathological changes in the mammary gland, in 183 cases the cytological investigation was followed by the histological one. The method proved to be of diagnostic value in 86% (sensitivity). Together with other methods of clinical diagnostics (palpation, mammography, xeromammography, thermography) the method concerned may widen the diagnostic opportunities and allows getting the information on the morphological nature of the tumor. Due to this, the practical application of this prompt, economic and devoid of any complications method seems to be rational. It is suggested to employ it routinely in the clinical practice.

[Causes of death in cancer patients]. / Daganatos betegek halálokai.

Causes of death of 260 tumorous patients autopsied in 1974 were analyzed. Most common causes were inflammation and tumorous and non-tumorous organ insufficiencies; the others, in order of decreasing incidence, massive tumorous dissemination, infarct and haemorrhage. Pneumonia was predominating over the inflammatory causes although peritonitis and sepsis were also not rarely encountered. Death due to inflammation occurred most frequently in cases of myeloid-lymphoid, urogenital and gastro-intestinal tumours and in postoperative states. The incidence of insufficiencies due to tumorous or non-tumorous origin differed but slightly. Of the various organ insufficiencies, massive hepatic metastases, occlusion of the biliary duct and cardiac failure were the most common. In cases of tumors of the small pelvis, compression of the ureters led most often to death. Massive dissemination was observed most of all in breast and ovarian carcinomas. Myeloid-lymphoid tumors led to death through extensive organ infiltration in about one thirds of the cases. After hearth infarction, venous thrombosis was often followed by pulmonary embolism, however, coronary occlusion was also not rare. Death due to haemorrhage originated from acute or chronic ulcers of the gastrointestinal tract or from vascular invasion of tumors in the head and neck regions or from thrombocytopaenia induced by cytostatics.

[Clinicopathological experiences in oncologic diseases]. / Klinikopatológiai tanulságok daganatos betegségben.

Authors on the base of the study of clinical history and autopsy protocols of 260 patients died in 1974 in the Institute of Oncology of Hungary from oncological diseases established, that the proportion of decised younger 30 years and the number of those older 70 years increased in comparison with 1964. In the autopsy material the most frequent were tumours of the lymphoid-myeloid system, then followed the frequency of the tumours of the breast and urogenital tract, the least frequent were the tumours of the gastrointestinal tract. Number of the primary multiplex tumours during the last 10 years increased from 1,5 per cent to 5,5 per cent. In 23,5 per cent of the cases medica negligence or that of the patient itself could be proved. The clinical and the pathological diagnosis did not correlate in 35,9 per cent of the cases studied. The most common unrecognized complication was pneumonia. Surgical treatment appeared to be most effective in cases of the cancer of the breast. The average age of the patients suriving for a longer period after the operation was 62,8 years, which seems to evidence, that prognosis of oncological diseases in older ages is better than in younger. In comparison with the data in 1964 number of cases with five year surviving increased by 3,7 per cent. This was striking first of all in cases of lymphoid-myeloid tumours.