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Cervical Cancer Screening

Information for Patients and the Public
Information for Health Professionals / Researchers
Latest Research Publications
Cervical Cancer
Human Papillomavirus (HPV), Vaccination, and Cervical Cancer

Information Patients and the Public (8 links)

Information for Health Professionals / Researchers (6 links)

Latest Research Publications

This list of publications is regularly updated (Source: PubMed).

Bergeron C, von Knebel Doeberitz M
The Role of Cytology in the 21st Century: The Integration of Cells and Molecules.
Acta Cytol. 2016; 60(6):540-542 [PubMed] Related Publications
OBJECTIVES: Cervical cancer screening test performance has been hampered by either a lack of sensitivity in Pap cytology or a lack of specificity of human papillomavirus (HPV) testing. This is disturbing for patients and a cause of high costs for health care providers.
STUDY DESIGN: The identification of p16INK4a as a specific marker for the neoplastic transformation of cervical squamous epithelial cells by HPVs allows the identification of HPV-transformed cells in cytopathology specimens.
RESULTS: When compared to molecular HPV tests for triaging minor cytologic atypia, such as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions, the immunochemical detection of dual p16INK4a/Ki-67-stained cells demonstrates a significantly improved specificity with good relative sensitivity.
CONCLUSIONS: HPV testing has shown earlier detection of persistent high-grade squamous intraepithelial lesions (HSIL) compared to cytology and is more effective in preventing invasive cervical cancer. The next challenge for the HPV primary screening program is to find the best method(s) for selecting, among HPV-positive women, those patients in need of immediate colposcopy because they are at a higher risk of developing a precancerous lesion. An HSIL cytology result and/or dual p16/Ki-67 staining could be the best candidates, but further randomized studies are required before these approaches can be used in routine practice.

Veijalainen O, Kares S, Kujala P, et al.
Human papillomavirus test with cytology triage in organized screening for cervical cancer.
Acta Obstet Gynecol Scand. 2016; 95(11):1220-1227 [PubMed] Related Publications
INTRODUCTION: In randomized studies, testing for high-risk (HR) human papillomavirus (hrHPV) has been more sensitive than conventional cytology in detecting cervical intraepithelial neoplasia (CIN). The aim of this study was to evaluate the performance of HPV testing in the setting of an organized routine screening program.
MATERIAL AND METHODS: Since 2012, 35- to 60-year-old women living in the city of Tampere have been screened with the Abbott RealTime hrHPV test. HPV-negative women are referred to the next screening round in five years. HPV-positive women are triaged with conventional cytology, and women with at least low-grade squamous intraepithelial lesion (LSIL(+) ) are referred to colposcopy. The remaining HPV-positive women are referred for re-testing after 12 months, and then all HPV-positive women are referred to colposcopy. The data from the last cohort with cytological screening (screened in 2011) is presented for comparison.
RESULTS: A total 5637 (70%) women attended the first round of HPV screening, and 369 were HPV-positive. Of them, 54 women LSIL(+) were referred to colposcopy, resulting in 16 CIN2(+) lesions found. Of the remaining HPV-positive women, 66% were still positive one year later, and were referred to colposcopy, with 18 additional CIN2(+) lesions found. The attendance rate to the last round of cytological screening was 71% (5814 women). Sixty-four women with LSIL(+) cytology were referred to colposcopy, and 11 CIN2(+) lesions were found. Of the 777 women with borderline cytology and scheduled for reflex screening in the following year, 109 (19%) had ASC-US(+) , and 57 underwent colposcopy, resulting in six additional CIN2(+) lesions found. The total detection rate of CIN2(+) was significantly higher in the HPV-screened cohort (6.0/1000 vs. 2.9/1000, p = 0.015). However, the total colposcopy rate was 4% vs. 2%, respectively (p < 0.001).
CONCLUSION: Human papillomavirus testing also seems to be more sensitive than cytology in detecting CIN2(+) lesions in the setting of a routine organized screening program, besides in the context of randomized trials. The problem of an increased colposcopy rate needs to be addressed in the future.

Li D, Chen L, Wang H, et al.
Clinical application of a rapid cervical cancer screening method: Folate receptor-mediated staining of cervical neoplastic epithelia.
Asia Pac J Clin Oncol. 2017; 13(1):44-52 [PubMed] Related Publications
AIM: A newly developed cervical cancer screening method - folate receptor-mediated epithelium staining utilizes methylene blue internalized by folate receptor-mediated endocytosis to stain cervical intra-epithelial neoplasia. We test the clinical feasibility of this method in this study.
METHODS: A total of 14 344 women who were at least 21 years old and had been sexually active, participated in the study. In gynecological clinics, participants underwent cervical cancer screening with folate receptor-mediated epithelium staining followed by cytology sampling. The color change of methylene blue in the cervical neoplastic epithelium can then be detected by the cotton swabs placed inside the cervix. A change of color to blue, bluish black or black is positive, whereas a change of color to green or no color change indicates negative result. Three hundred and twenty-three women who were positive with either or both tests had histopathologic diagnosis.
RESULTS: The sensitivity, specificity, positive predictive value and negative predictive value of folate receptor-mediated epithelium staining for cervical intra-epithelial neoplasia grade 2 and worse was 85.7%, 76.4%, 61.3% and 92.5%, respectively. Folate receptor-mediated epithelium staining had moderate agreement with cytology thresholded at atypical squamous cells, unable to exclude a high grade intra-epithelial lesion and was more sensitive that the later (85.7% vs 74.5% for intra-epithelial neoplasia grade 2 and worse; 89.2% vs 75.4% for intra-epithelial neoplasia grade 3 and worse).
CONCLUSION: Folate receptor-mediated epithelium staining is capable of detecting cervical precancerous and cancerous lesions rapidly and cost-effectively.

Al-Mandeel HM, Sagr E, Sait K, et al.
Clinical Practice Guidelines on the Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention in Saudi Arabia.
Ann Saudi Med. 2016 Sep-Oct; 36(5):313-320 [PubMed] Related Publications
BACKGROUND: Cervical cancer is the third most common gynecological malignancy in Saudi women with an estimated incidence rate of 1.9 cases per 100 000 women-years. More than 40% of cervical cancer cases are diagnosed at advanced stages due to lack of a routine screening program in Saudi Arabia. Thus, national guidelines for routine screening and treatment of precancerous cervical lesions are needed.
METHODS: The Saudi Centre for Evidence-Based Healthcare invited a panel of local experts and partnered them with a team from McMaster University in Canada for methodological support, to develop national clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer. After the panel identified key clinical questions, the McMaster University working group updated existing systematic reviews that had been used for the 2013 WHO Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Recommendations were based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. Those recommendations took into account the available evidence, patient values and preferences, and resource use in the Saudi context. The panel provided recommendations on two major issues: screening for precancerous lesions (cervical intraepithelial neoplasia 2 & 3) and treatment of those lesions to prevent cervical cancer in women who tested positive after screening.
CONCLUSIONS: The Saudi expert panel recommends using the HPV DNA test followed by colposcopy or cytology (Pap test) followed by colposcopy to screen for CIN2+ in women at risk of cervical cancer. The panel recommends cryotherapy or loop excision electrosurgery procedure (LEEP) over cold knife cone biopsy to treat women at risk of cervical cancer that tests positive for CIN2+. Universal screening for precancerous cervical dysplasia in women in Saudi Arabia is recommended using HPV testing and or cytology. Either cryotherapy or LEEP are preferred for treatment.
LIMITATIONS: National studies on cervical cancer screening modalities and treatment of precancerous cervical lesions, including HPV prevalence and its association with cervical cancer, are scarce.

Malhotra C, Bilger M, Liu J, Finkelstein E
Barriers to Breast and Cervical Cancer Screening in Singapore: a Mixed Methods Analysis.
Asian Pac J Cancer Prev. 2016; 17(8):3887-95 [PubMed] Related Publications
BACKGROUND: In order to increase breast and cervical cancer screening uptake in Singapore, women's perceived barriers to screening need to be identified and overcome. Using data from both focus groups and surveys, we aimed to assess perceived barriers and motivations for breast and cervical cancer screening.
MATERIALS AND METHODS: We conducted 8 focus groups with 64 women, using thematic analysis to identify overarching themes related to women's attitudes towards screening. Based on recurring themes from focus groups, several hypotheses regarding potential barriers and motivations to screen were generated and tested through a national survey of 801 women aged 25-64.
RESULTS: Focus group participants had misconceptions related to screening, believing that the procedures were painful. Cost was an issue, as well as efficacy and fatalism.
CONCLUSIONS: By identifying barriers to and motivators for screening through a mixed-method design that has both nuance and external validity, this study offers valuable suggestions to policymakers to improve breast and cervical cancer screening uptake in Singapore.

Aminisani N, Fattahpour R, Abedi L, Shamshirgaran SM
Determinants of Cervical Cancer Screening Uptake in Kurdish Women Living in Western Iran, 2014.
Asian Pac J Cancer Prev. 2016; 17(8):3763-7 [PubMed] Related Publications
BACKGROUND: Cervical cancer is the second most common cancer among females across the world. It is a preventable cancer and early detection is very feasible. This study aimed to identify which women characteristics are potentially associated with and may have an important influence on the uptake of cervical cancer screening in Kurdish women living in the west of Iran..
MATERIALS AND METHODS: A cross sectional study was conducted in late 2014. A random sample of women aged 40 years and above without history of cervical cancer and identi ed as Kurdish background were selected and interviewed by two trained interviewers. Information about sociodemographic and reproductive factors, history of diseases, and cervical screening was collected using a questionnaire and women who had undergone a hysterectomy were excluded. Univariate analyses were used to describe the general characteristics of the study population. Multivariable logistic regression models with self-reported screening history were used to estimate odds ratios (ORs) with 95% con dence intervals (CI). Significance was considered at the 5% level.
RESULTS: A total of 561 women were included in this study (mean age 43.6±5.17 years) participation in cervical screening at least once was about 32%. Cervical screening uptake percentage was significantly lower among people over 60 years of age (adjusted OR= 0.26, 95% CI: 0.11-0.64), and those who were illiterate (OR=0.41 95% CI: 0.23-0.73) and post-menopausal (OR= 0.56, 95% CI: 0.35- 0.91). Women with ≤1 child were less likely to report a Pap test (adjusted OR=.43 95%CI: 0.13-1.37) Cervical screening uptake was higher among women with health insurance (OR= 2.31, 95% CI: 1.50- 3.56).
CONCLUSIONS: Cervical screening participation in this study was low compared to other studies in developed countries. The screening uptake was different based on age, education, parity, insurance coverage and menopausal status. It is recommended to target these groups of women in a cervical screening program.

Wright TC, Stoler MH, Aslam S, Behrens CM
Knowledge of Patients' Human Papillomavirus Status at the Time of Cytologic Review Significantly Affects the Performance of Cervical Cytology in the ATHENA Study.
Am J Clin Pathol. 2016; 146(3):391-8 [PubMed] Related Publications
OBJECTIVES: With human papillomavirus (HPV) testing, patients' HPV status may be known when reviewing cytology specimens.
METHODS: 41,955 women 25 years or older had cytology and HPV screening. Originally, cytology was reviewed blinded to HPV status. We re-reviewed unblinded to HPV status a subset of 428 cytology slides from women with cervical intraepithelial neoplasia grade 2 + (CIN2+) and 1,287 from women without CIN2+.
RESULTS: Of the original interpretations of atypical squamous cells of undetermined significance (ASC-US), 33.7% were downgraded to negative after unblinded review, and 8.7% were upgraded to atypical squamous cells, cannot rule out a high-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. Of the original interpretations of ASC-US, 66.7% were downgraded on unblinded review in HPV-negative women and 30.2% were upgraded in HPV 16+/HPV 18+ women. Unblinding increases the sensitivity for cervical intraepithelial neoplasia grade 3+ of cotesting from 54.1% to 62.4% (P = .0015) and the sensitivity of HPV primary screening from 72.2% to 77.1% (P = .0029). With cotesting, specificity with unblinding is improved, whereas with HPV primary screening, there would be a small decrease in specificity.
CONCLUSIONS: Unblinded cytology increases overall sensitivity with either cotesting or HPV primary screening; specificity is either slightly improved or is not affected by unblinding.

Othman NH, Zaki FH, Hussain NH, et al.
SelfSampling Versus Physicians' Sampling for Cervical Cancer Screening Agreement of Cytological Diagnoses.
Asian Pac J Cancer Prev. 2016; 17(7):3489-94 [PubMed] Related Publications
BACKGROUND: A major problem with cervical cancer screening in countries which have no organized national screening program for cervical cancer is suboptimal participation. Implementation of selfsampling method may increase the coverage.
OBJECTIVE: We determined the agreement of cytological diagnoses made on samples collected by women themselves (selfsampling) versus samples collected by physicians (Physician sampling).
MATERIALS AND METHODS: We invited women volunteers to undergo two procedures; cervical selfsampling using the Evalyn brush and physician sampling using a Cervex brush. The women were shown a video presentation on how to take their own cervical samples before the procedure. The samples taken by physicians were taken as per routine testing (Gold Standard). All samples were subjected to Thin Prep monolayer smears. The diagnoses made were according to the Bethesda classification. The results from these two sampling methods were analysed and compared.
RESULTS: A total of 367 women were recruited into the study, ranging from 22 to 65 years age. There was a significant good agreement of the cytological diagnoses made on the samples from the two sampling methods with the Kappa value of 0.568 (p=0.040). Using the cytological smears taken by physicians as the gold standard, the sensitivity of selfsampling was 71.9% (95% CI:70.972.8), the specificity was 86.6% (95% CI:85.7 87.5), the positive predictive value was 74.2% (95% CI:73.375.1) and the negative predictive value was 85.1% (95% CI: 84.286.0). Selfsampling smears (22.9%) allowed detection of microorganisms better than physicians samples (18.5%).
CONCLUSIONS: This study shows that samples taken by women themselves (selfsampling) and physicians have good diagnostic agreement. Selfsampling could be the method of choice in countries in which the coverage of women attending clinics for screening for cervical cancer is poor.

Placidi A, Capparucci P, Di Luzio A, et al.
Team Reading (Peer Review) of Suspicious/Positive Slides for Continuous Quality Improvement in Cervical-Vaginal Cytology: A Comparison between Methods and Indicators.
Acta Cytol. 2016; 60(5):458-464 [PubMed] Related Publications
AIM: In 2013, the Local Health Unit Roma 2 ex C screening laboratory introduced a new set of indicators for quality assurance. We compare 2 sets of indicators based on routine multiple readings (peer review) for their ability to identify problems in single-reader accuracy.
METHODS: All suspect slides were blindly reviewed by all the cytologists of the laboratory. The standard set of indicators includes interreader Cohen's kappa, positivity rate and atypical squamous cell of undetermined significance/squamous intraepithelial lesion (ASC-US/SIL) ratio. The new set included sensitivity for cervical intraepithelial neoplasia of grade 2 or worse (CIN2+), positive predictive value (PPV) and percentage of positive high-risk (HR)-HPV cases among ASC-US. In order to estimate sensitivity and PPV, we considered all women for whom there was a consensus of negative cytology, negative HR-HPV test, negative colposcopy or negative histology true negative.
RESULTS: Kappa values ranged from 0.521 to 0.753, with narrow 95% confidence intervals (CIs). Positivity rate ranged from 73.9 to 85.7 and the ASC-US/SIL ratio from 0.61 to 0.81. Sensitivity for CIN2+ at the low-grade SIL threshold ranged from 85.8 to 94.2, PPV ranged from 14.8 to 19.4, and both had a broad 95% CI. Readers with low sensitivity did not show low kappa values. The percentage proportion of HR-HPV-positives (HR-HPV+) among ASC-US ranged from 39.9 to 43.8% with a narrow 95% CI.
CONCLUSION: The proportion of HR-HPV+ among ASC-US cases is a powerful indicator to address in training.

Cvijović J, Milica Kostić-Stanković, Krstić G, Stojanović L
Marketing communication in the area of breast and cervical cancer prevention.
Vojnosanit Pregl. 2016; 73(6):544-52 [PubMed] Related Publications
BACKGROUND/AIM: Innovative marketing campaigns and promotional activities can successfully contribute to the improvement of public health by raising the level of general knowledge about health issues and benefits that the change of habits, eradication of undesirable behaviour and regular medical controls have. The focus should be on continuous marketing communication through various mass media or direct communication between medical staff and patients. The aim of this paper was to define the role that various communication channels have in the process of informing and educating the target group in case of breast and cervical cancer prevention.
METHODS: The survey based on polling a sample of 2,100 female patients of the Serbian Railways Medical Centre was conducted in the period October- December 2013. The questionnaire included questions about demographic characteristics, prevention habits of women, their level of information on that topic and communication channels they prefer.
RESULTS: There is a difference among respondents' awareness level about preventive measures depending on demographic and geographical criteria. The results indicate the existence of variations in frequency of performing gynaecological examinations and Pap tests depending on different age, educational and residential groups. Although the largest percentage of women stated familiarity with the way of performing breast self-examination (78%), the majority of them had never performed mammography or ultrasonography (67%). The greatest number of women were informed about the possibility of preventing breast and cervical cancer by posters or brochures in health institutions (71%) and mass media--television on the first place (74%), then specialized magazines about health (48%), radio (48%), web sites about health (42%), and daily newspapers (34%). The respondents consider the Ministry of Health and health institutions as the most responsible subjects for education of women about cancer prevention, while the self-initiative was given the least importance.
CONCLUSION: Determined informing habits of the target group, their prevention habits and attitudes on the subject should be used as the basis for planning and implementation of prevention marketing campaigns that would be the most effective.

Chen CC, Huang LW, Bai CH, Lee CC
Predictive value of p16/Ki-67 immunocytochemistry for triage of women with abnormal Papanicolaou test in cervical cancer screening: a systematic review and meta-analysis.
Ann Saudi Med. 2016 Jul-Aug; 36(4):245-51 [PubMed] Related Publications
BACKGROUND: The Papanicolaou (Pap) test is one screening strategy used to prevent cervical cancer in developed countries. The p16/Ki-67 immunocytochemistry is a triage test performed on Pap smears in women with atypical squamous cells of undetermined significance (ASCUS) or low grade squamous intraepithelial lesion.
OBJECTIVE: Our objective was to review studies investigating the diagnostic performance of p16/Ki-67 dual stain for triage of women with abnormal Pap tests.
DESIGN: We conducted a systematic review and meta-analysis of diagnostic test accuracy studies.
SETTINGS: We followed the protocol of systematic review of diagnostic accuracy studies.
PATIENTS AND METHODS: We searched PubMed, The Cochrane Library, BioMed Central, and ClinicalTrials.gov for relevant studies. We included research that assessed the accuracy of p16/Ki-67 dual stain and high risk human papillomavirus testing for triage of abnormal Pap smears. Review articles and studies that provided insufficient data to construct 2.2 tables were excluded. Data synthesis was conducted using a random-effects model.
MAIN OUTCOME MEASURES: Sensitivity and specificity.
RESULTS: In seven studies encompassing 2628 patients, the pooled sensitivity and specificity of p16/Ki-67 for triage of abnormal Pap smear results were 0.91 (95% CI, 0.89 to 0.93) and 0.64 (95% CI, 0.62 to 0.66), respectively. No study used a case-control design. A subgroup analysis involving liquid-based cytology showed a sensitivity of 0.91 (95%CI, 0.89 to 0.93) and specificity of 0.64 (95%CI, 0.61 to 0.66).
CONCLUSIONS: Our meta-analysis of p16/Ki-67 dual stain studies showed that the test achieved high sensitivity and moderate specificity for p16/Ki-67 immunocytochemistry for high-grade squamous intraepi.thelial lesion and cervical cancer. We suggest that p16/Ki-67 dual stain might be a reliable ancillary method identifying high-grade squamous intraepithelial lesions in women with abnormal Pap tests.
LIMITATIONS: No study in the meta-analysis examined the accuracy of the p16/Ki-67 dual stain for inter.pretation of glandular neoplasms.

Huangfu M, Liu L, Xu S, et al.
Detecting of p16 Autoantibody as a Potential Early Diagnostic Serum Biomarker in Patients with Cervical Cancer.
Clin Lab. 2016; 62(6):1117-20 [PubMed] Related Publications
BACKGROUND: Over-expression of tumor-associated antigens (TAAs) may trigger secretion of their auto-antibodies. The present work was designed to test whether circulating antibody to P16 protein-derived antigens was altered in cervical cancer.
METHODS: 141 cases of cervical cancer patients, 133 cases of cervical benign tumor patients, and 153 healthy volunteers matched in age were recruited. The level of circulating P16 auto-antibody was tested using an ELISA developed in-house with linear peptide antigens derived from the P16 protein.
RESULTS: The P16 auto-antibody in the malignant tumor group had a significantly higher level than the healthy control group and the benign tumor group (t = 4.016, p < 0.001; t = 3.879, p < 0.001). Patients with stage I cervical cancer have the highest level of P16 autoantibody and the sensitivity against > 90% specificity was 20.3%.
CONCLUSIONS: The circulating auto-antibody to P16 may be one of a series of potential biomarkers with early prognostic values for cervical cancer.

Isaka Y, Inada H, Hiranuma Y, Ichikawa M
Psychological impact of positive cervical cancer screening results among Japanese women.
Int J Clin Oncol. 2017; 22(1):102-106 [PubMed] Related Publications
BACKGROUND: While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening.
METHODS: We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress.
RESULTS: Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32-3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69-3.01) and marital status (OR 1.32; 95 % CI 1.02-1.70).
CONCLUSIONS: Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

Mishra GA, Pimple SA, Shastri SS
Prevention of Cervix Cancer in India.
Oncology. 2016; 91 Suppl 1:1-7 [PubMed] Related Publications
Cervical cancer is the fourth most common cancer among women globally and the second most common cancer among Indian women. India alone bears 23% of the global cervical cancer burden. In India, population-based cervical cancer screening is largely nonexistent in most regions due to competing healthcare priorities, insufficient financial resources and a limited number of trained providers. Hence, most of the cases present in advanced stages of the disease, thus leading to increased mortality and reduced survival. Various screening options like cytology, visual-based screening and testing for high-risk HPV are available. Several cross-sectional studies have looked at the comparative efficacy of different screening tests. Three important randomized controlled trials from India have shown the efficacy of screening once in a life time with HPV DNA, one-time screening with VIA by trained nurses and four-time screening with VIA by trained primary health workers, reducing mortality due to cervical cancers. Prevention of cervical cancers with two-dose HPV vaccination and early detection of precancerous cervical lesions of the eligible population through screening and their appropriate treatment with a single-visit 'screen-and-treat' approach appear to be promising for low-middle-income countries including India.

Di JL, Rutherford S, Wu JL, et al.
Knowledge of Cervical Cancer Screening among Health Care Workers Providing Services Across Different Socio-economic Regions of China.
Asian Pac J Cancer Prev. 2016; 17(6):2965-72 [PubMed] Related Publications
BACKGROUND: China carries a heavy burden of cervical cancer (CC) and substantial disparities exist across regions within the country. In order to reduce regional disparities in CC, the government of China launched the National Cervical Cancer Screening Program in Rural Areas (NCCSPRA) in 2009. Critical to the success of the program are the health care workers who play a pivotal role in preventing and managing CC by encouraging and motivating women to use screening services and by providing identification and treatment services. This study aimed to assess cervical cancer knowledge among these health care workers at the county level in maternal and child health (MCH) hospitals across different socio-economic regions of China.
MATERIALS AND METHODS: A cross-sectional survey was conducted and self-administered questionnaires were sent to all health care workers (a total of 66) providing cervical cancer screening services in 6 county level MCH hospitals in Liaoning, Hubei and Shaanxi provinces, representing eastern, central and western regions of China; 64 (97.0%, 64/66) of the workers responded. ANOVA and Chi-square test were used to compare the knowledge rate and scores in subgroups.
RESULTS: The knowledge level of the respondents was generally low. The overall combined knowledge rate was 46.9%. The knowledge rates for risk factors, prevention, clinical symptoms, screening and diagnostic tests and understanding of positive results were 31.3%, 37.5%, 18.1%, 56.3% and 84.4%, respectively. Statistically significant differences in scores or rates of CC knowledge were seen across the different regions. The total and sectional scores in the less developed regions were statistically significantly lower than in the other regions.
CONCLUSIONS: The majority of the health care workers who provide CC screening service in NCCSPRA at county level MCH hospitals do not have adequately equipped with knowledge about CC. Given the importance of knowledge to the program's success in reducing CC burden in rural women in China, efforts are needed to improve the knowledge of health care workers, especially in less developed regions.

Shobeiri F, Javad MT, Parsa P, Roshanaei G
Effects of Group Training Based on the Health Belief Model on Knowledge and Behavior Regarding the Pap Smear Test in Iranian Women: a Quasi-Experimental Study.
Asian Pac J Cancer Prev. 2016; 17(6):2871-6 [PubMed] Related Publications
The Pap smear test is recommended for early diagnosis of cervical cancer. The aim of this study was to assess knowledge and behavior regarding the Pap smear test based on the Health Belief Model (HBM) in women referred to premarital counseling classes, Hamadan, Iran. This quasi-experimental study was conducted on 330 women, who were allocated randomly to two case and control groups (n=165). Two educational session classes were performed in the case group. Two stages in before and after intervention groups were evaluated. Analysis of data was performed by SPSS/16.0, using t-test, x2, and McNemar's test. P-values <0.05 were regarded as significant. There was no significant difference between the mean scores of the various structures of this model in two groups before the intervention. However, after the intervention there were significant increase in mean score of knowledge and all variables of HBM in the intervention group(<0.001). The findings of this study highlight the important role of education about cervical cancer on changing women's beliefs about cervical screening.

Liou YL, Zhang TL, Yan T, et al.
Combined clinical and genetic testing algorithm for cervical cancer diagnosis.
Clin Epigenetics. 2016; 8:66 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Opportunistic screening in hospitals is widely used to effectively reduce the incidence rate of cervical cancer in China and other developing countries. This study aimed to identify clinical risk factor algorithms that combine gynecologic examination and molecular testing (paired box gene 1 (PAX1) or zinc finger protein 582 (ZNF582) methylation or HPV16/18) results to improve diagnostic accuracy.
METHODS: The delta Cp of methylated PAX1 and ZNF582 was obtained via quantitative methylation-specific PCR in a training set (57 CIN2- and 43 cervical intraepithelial neoplasia ≥grade 3 (CIN3+) women), and the individual and combination gene sensitivities and specificities were determined. The detection accuracy of three algorithms combining gynecologic findings and genetic test results was then compared in a randomized case-control study comprising 449 women referred for colposcopic examination by gynecologists in the outpatient department of Xiangya Hospital between November 2011 and March 2013.
RESULTS: Significant association was observed between CIN3+ and methylated PAX1 or ZNF582 in combination with HPV16/18 (OR:15.52, 95 % CI:7.73-31.18). The sensitivities and specificities of methylated PAX1 or ZNF582 combined with HPV16/18 for CIN3+ women were 89.2 and 76.0 %, or 85.4 and 80.1 %, respectively. Of the three algorithms applied to cohort data and validated in the study, two indicated 100 % sensitivity in detecting cervical cancer and a low rate of referrals for colposcopy.
CONCLUSIONS: These algorithms might contribute to precise and objective cervical cancer diagnostics in the outpatient departments of hospitals in countries with high mortality and low screening rates or areas with uneven resource distribution.

Tsikouras P, Zervoudis S, Manav B, et al.
Cervical cancer: screening, diagnosis and staging.
J BUON. 2016 Mar-Apr; 21(2):320-5 [PubMed] Related Publications
Purpose: Despite the widespread screening programs, cervical cancer remains the third most common cancer in developing countries. Based on the implementation of cervical screening programs with the referred adoption of improved screening methods in cervical cytology with the knowledge of the important role of the human papilloma virus (HPV) it's incidence is decreased in the developed world. Even if cervical HPV infection is incredibly common, cervical cancer is relatively rare. Depending on the rarity of invasive disease and the improvement of detection of pre-cancerous lesions due to the participation in screening programs, the goal of screening is to detect the cervical lesions early in order to be treated before cancer is developed. In populations with many preventive screening programs, a decrease in cervical cancer mortality of 50-75% is mentioned over the past 50 years. The preventive examination of vagina and cervix smear, Pap test, and the HPV DNA test are remarkable diagnostic tools according to the American Cancer Association guidelines, in the investigation of asymptomatic women and in the follow up of women after the treatment of pre-invasive cervical cancer. The treatment of cervical cancer is based on the FIGO 2009 cervical cancer staging.

Kittisiam T, Tangjitgamol S, Chaowawanit W, et al.
Knowledge and Attitudes of Bangkok Metropolitan Women towards HPV and Self-Sampled HPV Testing.
Asian Pac J Cancer Prev. 2016; 17(5):2445-51 [PubMed] Related Publications
BACKGROUND: To evaluate knowledge of Bangkok women regarding HPV and self-sampled HPV testing, and their attitudes towards testing.
MATERIALS AND METHODS: Thai women who had lived in Bangkok for more than 5 years, aged 25-to-65 years old, were invited to join the study. Participating women were asked to a complete self-questionnaire (Thai language), with literate assistance as needed. The questionnaire was divided into 3 parts: (I) demographic data, (II) knowledge and (III) attitudes towards self-sampled HPV testing. Before proceeding to Part III of the questionnaire, a 15-minute educational video of self-sampled HPV testing was presented to all participants.
RESULTS: Among 2,810 women who answered the questionnaires, 33.7% reported that they did not know about HPV. The characteristic features of these women were older age (>50 years), lower income (<600 USD/month), unemployed status, and non-attendees at cervical cancer screening. Only small numbers of women (4.6%) responded that they had heard about self-sampled HPV testing. After having information, 59.6% would not use the self-sampled HPV testing as a method of cervical cancer screening (non-acceptance). Factors significantly associated with the non-acceptance were older age, lower income, having no knowledge about HPV or self-collected HPV testing, a perception that the testing was unreliable and a concern that they might not be able to perform it correctly.
CONCLUSIONS: Nearly half and almost all Bangkok women did not know about HPV and self-sampled HPV testing, respectively. Approximately 60% of Bangkok women refused to do the self-sampled HPV testing. Significant negative attitudes were concerns that the testing would be unreliable and a lack of confidence to perform the procedure correctly. Education about HPV and self-sampled HPV testing, ease of the procedure, or the testing models may increase rate of acceptability or positive attitudes.

Johnson MJ, Mueller M, Eliason MJ, et al.
Quantitative and mixed analyses to identify factors that affect cervical cancer screening uptake among lesbian and bisexual women and transgender men.
J Clin Nurs. 2016; 25(23-24):3628-3642 [PubMed] Related Publications
AIMS AND OBJECTIVES: The purposes of this study were to measure the prevalence of, and identify factors associated with, cervical cancer screening among a sample of lesbian, bisexual and queer women, and transgender men.
BACKGROUND: Past research has found that lesbian, bisexual and queer women underuse cervical screening service. Because deficient screening remains the most significant risk factor for cervical cancer, it is essential to understand the differences between routine and nonroutine screeners.
DESIGN: A convergent-parallel mixed methods design.
METHODS: A convenience sample of 21- to 65-year-old lesbian and bisexual women and transgender men were recruited in the USA from August-December 2014. Quantitative data were collected via a 48-item Internet questionnaire (N = 226), and qualitative data were collected through in-depth telephone interviews (N = 20) and open-ended questions on the Internet questionnaire.
RESULTS: Seventy-three per cent of the sample was routine cervical screeners. The results showed that a constellation of factors influence the use of cervical cancer screening among lesbian, bisexual and queer women. Some of those factors overlap with the general female population, whereas others are specific to the lesbian, bisexual or queer identity. Routine screeners reported feeling more welcome in the health care setting, while nonroutine screeners reported more discrimination related to their sexual orientation and gender expression. Routine screeners were also more likely to 'out' to their provider. The quantitative and qualitative factors were also compared and contrasted.
CONCLUSIONS: Many of the factors identified in this study to influence cervical cancer screening relate to the health care environment and to interactions between the patient and provider.
RELEVANCE TO CLINICAL PRACTICE: Nurses should be involved with creating welcoming environments for lesbian, bisexual and queer women and their partners. Moreover, nurses play a large role in patient education and should promote self-care behaviours among lesbian women and transgender men.

Desire BK, Philippe CM, Thierry K, et al.
Visual inspection with acetic acid and Lugol's iodine in cervical cancer screening at the general referral hospital Kayembe in Mbuji-Mayi, Democratic Republic of Congo.
Pan Afr Med J. 2016; 23:64 [PubMed] Free Access to Full Article Related Publications
INTRODUCTION: Cervical cancer is the leading cause of morbidity and mortality of women from cancer in the developing World. It is the primary cause of reduced life expectancy in Sub-Saharan countries such as Democratic Republic of Congo. The aim of this work was to determinate the socio-demographic profile of women with precancerous and cancerous lesions of the cervix, to determinate the frequency of VIA and VILI positive cases and to show the challenges that can be faced in managing patients with abnormalities in the city of Mbuji-Mayi in the Democratic Republic of Congo.
METHODS: As part of its activities, the "Association de Lutte contre le Cancer du Col utérin" (ALCC) organized a community outreach followed by free voluntary testing for cervical cancer for two weeks (26(th)March to 10(th) April 2011) at the General Referral Hospital Kayembe in Mbuji-Mayi (Democratic Republic of Congo).
RESULTS: A total of 229 women were examined. 38% of tests (VIA + VILI) were positive with 6 clinically suspected cases of invasive cancer at stage 1 (7% of cases). Nearly 70% of patients were still of childbearing age and had started their first sexual intercourse before 18 years of age and 86% of cases were multiparous. Given the material, financial and technical constraints, 75% of patients were placed in a monitoring program of 9 months to 1 year (= expectation and another test) while 11% of them were selected for a biopsy to be locally practiced and sent to the pathologist. Nearly 8% of the cases were candidates for hysterectomy.
CONCLUSION: Given the difficulties encountered and the frequency of positive tests, we recommend another study with a larger sample, improved working conditions (mainly equipment) and the association of another test such as the Human Papilloma Virus (HPV) test.

Ahmadipour H, Sheikhizade S
Breast and Cervical Cancer Screening in Women Referred to Urban Healthcare Centers in Kerman, Iran, 2015.
Asian Pac J Cancer Prev. 2016; 17 Spec No.:143-7 [PubMed] Related Publications
Breast and cervical cancers are among leading causes of morbidity and mortality in women worldwide. Regular screening is very important for early detection of these cancers, but studies indicate low rates of screening participation. In this survey we studied the rate of screening participation among women 18-64 years old referred to urban health centers in Kerman, Iran in 2015. A cross-sectional study was carried out on 240 women who were selected using a multistage sampling method. Data collected using a questionnaire covered demographics and questions about common cancer screening status in women. Analysis was by SPSS 19. The mean age of participants was 31.7± 7. Most (97.1%) were married, housewives (83.3%), had high school diploma (43.8%) and a monthly income more than ten million Rls. The frequency of the Pap test performance was higher in women who were employed and with a university degree (p<0.05). The frequency of mammography performance in women over 40 years was also higher in women with university degree (p<0.05). There was no statistically significant difference in the frequency of pelvic examination, and self and clinical breast examinations based on education, household income and employment (p>0.05). Our study found that the rate of screening participation among women is low. Investigation of the barriers, increasing the awareness of women about the importance and advantages of screening and also more incentives for health personnel especially family physicians to pay more attention to preventive programs could be effective.

Kolthoff SK, Hestbech MS, Jørgensen KJ, Brodersen J
Do invitations for cervical screening provide sufficient information to enable informed choice? A cross-sectional study of invitations for publicly funded cervical screening.
J R Soc Med. 2016; 109(7):274-81 [PubMed] Free Access to Full Article Related Publications
OBJECTIVE: To investigate whether invitations for publicly funded cervical screening provide sufficient information to enable an informed choice about participation.
DESIGN: Cross-sectional study using a checklist of 23 information items on benefits and harms from cervical screening and the risks related to cervical cancer.
MATERIAL: Invitations to publicly funded cervical screening in 10 Scandinavian and English-speaking countries.
SETTING: Ten Scandinavian and English speaking countries.
PARTICIPANTS: Sixteen screening units representing 10 Scandinavian and English speaking countries.
MAIN OUTCOME MEASURES: Number of information items presented in invitations for cervical screening.
RESULTS: We contacted 21 coordinating units from 11 countries and 20 (95%) responded. Of these, four units did not issue invitations, but the remaining 16 coordinating units in 10 different countries supplied a sample. The invitations for cervical screening were generally information poor and contained a median of only four out of 23 information items possible (17%), ranging from 0 to 12 (0-52%). The most important harms of cancer screening, overdiagnosis and overtreatment, were typically downplayed or unmentioned. The same applied to other important harms, such as false-positive results and the psychological consequences from an abnormal test result. The majority of invitations took a paternalistic approach. While only two invitations (17%) included a pre-assigned appointment date, eight (70%) of the invitations contained strong appeals for participation.
CONCLUSIONS: Invitations to cervical cancer screening were information poor and biased in favour of participation. This means that informed choice is not possible, which is in conflict with modern requirements for personal involvement in medical decisions.

Shoemaker ML, White MC
Breast and cervical cancer screening among Asian subgroups in the USA: estimates from the National Health Interview Survey, 2008, 2010, and 2013.
Cancer Causes Control. 2016; 27(6):825-9 [PubMed] Related Publications
PURPOSE: This study describes variations in mammography and Pap test use across and within subgroups of Asian women in the USA.
METHODS: Using data from the National Health Interview Survey (2008, 2010, and 2013), we calculated weighted proportions for selected Asian subgroups (Asian Indian, Chinese, Filipino, Other Asian) of women reporting mammography and Pap test use.
RESULTS: The proportion of women aged 50-74 years who reported a mammogram within the past 2 years did not differ significantly across Asian subgroups. The proportion of women aged 21-65 years who received a Pap test within the past 3 years differed significantly across Asian subgroups, with lower proportions among Asian Indian, Chinese, and Other Asian women. Recent immigrants, those without a usual source of care, and women with public or no health insurance had lower proportions of breast and cervical cancer screening test use.
CONCLUSIONS: Patterns of mammography and Pap test use vary among subgroups of Asian women, by length of residency in the USA, insurance status, usual source of care, and type of cancer screening test. These findings highlight certain Asian subgroups continue to face significant barriers to cancer screening test use.

Whop LJ, Baade P, Garvey G, et al.
Cervical Abnormalities Are More Common among Indigenous than Other Australian Women: A Retrospective Record-Linkage Study, 2000-2011.
PLoS One. 2016; 11(4):e0150473 [PubMed] Free Access to Full Article Related Publications
Indigenous Australian women have much higher incidence of cervical cancer compared to non-Indigenous women. Despite an organised cervical screening program introduced 25 years ago, a paucity of Indigenous-identified data in Pap Smear Registers remains. Prevalence of cervical abnormalities detected among the screened Indigenous population has not previously been reported. We conducted a retrospective cohort study of population-based linked health records for 1,334,795 female Queensland residents aged 20-69 years who had one or more Pap smears during 2000-2011; from linked hospital records 23,483 were identified as Indigenous. Prevalence was calculated separately for Indigenous and non-Indigenous women, for cytology-detected low-grade (cLGA) and high-grade abnormalities (cHGA), and histologically confirmed high-grade abnormalities (hHGA). Odds ratios (OR) were estimated from logistic regression analysis. In 2010-2011 the prevalence of hHGA among Indigenous women (16.6 per 1000 women screened, 95% confidence interval [CI] 14.6-18.9) was twice that of non-Indigenous women (7.5 per 1000 women screened, CI 7.3-7.7). Adjusted for age, area-level disadvantage and place of residence, Indigenous women had higher prevalence of cLGA (OR 1.4, CI 1.3-1.4), cHGA (OR 2.2, CI 2.1-2.3) and hHGA (OR 2.0, CI 1.9-2.1). Our findings show that Indigenous women recorded on the Pap Smear Register have much higher prevalence for cLGA, cHGA and hHGA compared to non-Indigenous women. The renewed cervical screening program, to be implemented in 2017, offers opportunities to reduce the burden of abnormalities and invasive cancer among Indigenous women and address long-standing data deficiencies.

Chaowawanit W, Tangjitgamol S, Kantathavorn N, et al.
Knowledge, Attitudes and Behavior of Bangkok Metropolitan Women Regarding Cervical Cancer Screening.
Asian Pac J Cancer Prev. 2016; 17(3):945-52 [PubMed] Related Publications
PURPOSE: To assess knowledge, attitudes and cervical cancer screening behavior of Bangkok Metropolitan women.
MATERIALS AND METHODS: Thai women, aged 25-to-65 years old, having lived in Bangkok for 5 years or more were invited to participate in the study. After signing informed consent, all women were asked to complete a self-questionnaire (Thai language) with literate assistance if needed. The questionnaire was divided into 3 parts: (I) demographic data; (II) knowledge about cervical cancer screening; and (III) behavior and attitudes, towards cervical cancer screening. Adequate screening was defined as women who had ≥two cervical cancer screening tests except women aged 25-30 years who may have only one screening, and the last screen was within 5 year or had had regular screening.
RESULTS: Of 4,339 women, there were 1,857 (42.8%) with adequate screening and 2,482 (57.2%) with inadequate screening. Significant factors associated with inadequate screening included age < 45 years, pre-menopausal status, family monthly income <625 USD, no reported sexual intercourse, nulliparous, no knowledge, lack of awareness and poor attitudes. Three major reasons provided by women for inadequate screening were no symptoms (54.4%), fear of pain (33.2%), and embarrassment (34.6%).
CONCLUSIONS: Personal features, knowledge, and attitudes influence screening behavior of Bangkok Metropolitan women. The three most common reasons of women for not undergoinging screening are no symptoms, fear of pain, and embarrassment. These factors should be the focus of attention to improve coverage of cervical cancer screening in Bangkok.

Ghahremani L, Harami ZK, Kaveh MH, Keshavarzi S
Investigation of the Role of Training Health Volunteers in Promoting Pap Smear Test Use among Iranian Women Based on the Protection Motivation Theory.
Asian Pac J Cancer Prev. 2016; 17(3):1157-62 [PubMed] Related Publications
BACKGROUND: Cervical cancer is known as one of the most prevalent types of cancers and a major public health problem in developing countries which can be detected by Pap test, prevented, and treated. Despite the effective role of Pap test in decreasing the incidence and mortality due to cervical cancer, it is still one the most common causes of cancer-related deaths among women, especially in developing countries. Thus, this study aimed to examine the effect of educational interventions implemented by health volunteers based on protection motivation theory (PMT) on promoting Pap test use among women.
MATERIALS AND METHODS: This quasi-experimental study was conducted on 60 health volunteers and 420 women. The study participants were divided into an intervention and a control group. Data were collected using a valid self-reported questionnaire including demographic variables and PMT constructs which was completed by both groups before and 2 months after the intervention. Then, the data were entered into the SPSS statistical software, version 19 and were analyzed using Chi-square test, independent T-test, and descriptive statistical methods. P<0.05 was considered as statistically significant.
RESULTS: The findings of this study showed that the mean scores of PMT constructs (i.e. perceived vulnerability, perceived severity, fear, response-costs, self-efficacy, and intention) increased in the intervention group after the intervention (P<0.001). However, no significant difference was found between the two groups regarding response efficacy after the intervention (P=0.06). The rate of Pap test use also increased by about 62.9% among the study women.
CONCLUSIONS: This study showed a significant positive relationship between PMT-based training and Pap test use. The results also revealed the successful contribution of health volunteers to training cervical cancer screening. Thus, training interventions based on PMT are suggested to be designed and implemented and health volunteers are recommended to be employed for educational purposes and promoting the community's, especially women's, health.

Constantinou P, Dray-Spira R, Menvielle G
Cervical and breast cancer screening participation for women with chronic conditions in France: results from a national health survey.
BMC Cancer. 2016; 16:255 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Comorbidity at the time of diagnosis is an independent prognostic factor for survival among women suffering from cervical or breast cancer. Although cancer screening practices have proven their efficacy for mortality reduction, little is known about adherence to screening recommendations for women suffering from chronic conditions. We investigated the association between eleven chronic conditions and adherence to cervical and breast cancer screening recommendations in France.
METHOD: Using data from a cross-sectional national health survey conducted in 2008, we analyzed screening participation taking into account self-reported: inflammatory systemic disease, cancer, cardiovascular disease, chronic respiratory disease, depression, diabetes, dyslipidemia, hypertension, obesity, osteoarthritis and thyroid disorders. We first computed age-standardized screening rates among women who reported each condition. We then estimated the effect of having reported each condition on adherence to screening recommendations in logistic regression models, with adjustment for sociodemographic characteristics, socioeconomic position, health behaviours, healthcare access and healthcare use. Finally, we investigated the association between chronic conditions and opportunistic versus organized breast cancer screening using multinomial logistic regression.
RESULTS: The analyses were conducted among 4226 women for cervical cancer screening and 2056 women for breast cancer screening. Most conditions studied were not associated with screening participation. Adherence to cervical cancer screening recommendations was higher for cancer survivors (OR = 1.73 [0.98-3.05]) and lower for obese women (OR = 0.73 [0.57-0.93]), when accounting for our complete range of screening determinants. Women reporting chronic respiratory disease or diabetes participated less in cervical cancer screening, except when adjusting for socioeconomic characteristics. Adherence to breast cancer screening recommendations was lower for obese women and women reporting diabetes, even after accounting for our complete range of screening determinants (OR = 0.71 [0.52-0.96] and OR = 0.55 [0.36-0.83] respectively). The lower breast cancer screening participation for obese women was more pronounced for opportunistic than for organized screening.
CONCLUSION: We identified conditions associated with participation in cervical and breast cancer screening, even when accounting for major determinants of cancer screening. Obese women participated less in cervical cancer screening. Obese women and women with diabetes participated less in mammographic screening and organized breast cancer screening seemed to insufficiently address barriers to participation.

Murphy J, Mark H, Anderson J, et al.
A Randomized Trial of Human Papillomavirus Self-Sampling as an Intervention to Promote Cervical Cancer Screening Among Women With HIV.
J Low Genit Tract Dis. 2016; 20(2):139-44 [PubMed] Article available free on PMC after 01/04/2017 Related Publications
OBJECTIVE: Women living with HIV experience higher risk of cervical cancer, but screening rates in the United States are lower than recommended. The purpose of this study was to examine whether an intervention using self-sampling of cervicovaginal cells for human papillomavirus (HPV) with results counseling would increase cervical cytology ("Pap") testing among women with HIV.
MATERIALS AND METHODS: This was a randomized controlled trial to test the effectiveness of an intervention of self-sampling for HPV and results counseling. Participants were 94 women older than 18 years, with HIV infection, attending an HIV clinic for a primary care visit, whose last cervical cancer screening was 18 months or more before baseline. Women were assigned to the intervention or information-only group. The primary outcome was completion of cervical cytology testing within 6 months of baseline. The secondary outcome was the women's perceived threat of developing cervical cancer.
RESULTS: A total of 94 women were enrolled and analyzed in the study. The cytology completion rate overall was 35% by 6 months from baseline. There were no differences in comparing HPV-positive with HPV-negative women nor comparing them with the information-only group. In the intervention group, a positive HPV test increased perceived threat of cervical cancer.
CONCLUSIONS: The intervention did not improve cytology test attendance, although education about HPV and cervical cancer risk as part of study procedures was associated with testing for 35% of this group of women whose previous cytology occurred an average of 3.6 years before the baseline appointment. Self-sampling for HPV testing was feasible.

Herbert A
Primary HPV testing: a proposal for co-testing in initial rounds of screening to optimise sensitivity of cervical cancer screening.
Cytopathology. 2017; 28(1):9-15 [PubMed] Related Publications
As explained by Kitchener in a previous issue of Cytopathology (2015;26:4-6), primary human papillomavirus (HPV) testing is likely to be introduced in the UK for all women aged 25-64 years following pilot site studies already in place. This will be necessary when the prevalence of cervical cancer and its precursors declines when vaccination takes effect but there is a risk in abandoning cytology as a primary test: a risk that would be most apparent in the present unvaccinated population in which the prevalence of cervical cancer and its precursors is exceptionally high. HPV testing is more sensitive than cytology but has a significant false-negative rate that could be detrimental to a successful screening programme if introduced without cytology backup. Accurate cytology would be needed for triage and could be compromised if HPV-negative tests were excluded from examination. This article proposes a compromise: cytology and HPV co-testing for the first two screening tests to optimise the sensitivity of the test as a whole. Registrations of invasive and in situ carcinoma of the uterine cervix in England indicate that the prevalence of the disease is highest in young women in the early rounds of screening. Calculations of the likely impact on the workload of this proposal have been based on a service evaluation of 295 cytology tests received at St Thomas' Hospital, which suggests that the volume of cytology tests would be reduced by approximately 60% compared with 80% for primary HPV testing alone. This proposal should be debated openly before irrevocable changes are made to a skilled workforce.

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