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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).

Galarowicz B, Jach R, Kidzierska J, et al.
The role of mRNA E6/E7 HPV high oncogenic risk expression in colposcopy of cervical intraepithelial neoplasia (CIN).
Przegl Lek. 2012; 69(9):651-7 [PubMed]
UNLABELLED: The aim of this paper is the evaluation of colposcopy and mRNA E6/E7 HPV detection--as the marker of persistent human papilloma virus (HPV) infection in the triage of abnormal Pap smears and in the assessment of cervical intraepithelial neoplasia progression risk. The clinical material consisted of 85 women, participating the national cervical cancer screening in the period of April 2010, and October 2010, reffered to the Outpatient Clinic of Gynecologic Oncology and Female Genital Tract Neoplasms Prophylaxy of the Jagiellonian University Medical College in Krakow, Poland. All subjects were offered gynecological evaluation, Pap smear, colposcopy, DNA HPV (Hybrid Capture2, Qiagen) and mRNA E6/E7 testing (NulciSens, Biomerieux). In case of positive tests colposcopically directed cervical biopsy with histopathologic evaluation were performed.
RESULTS: The presence of mRNA E6/E7 HPV transcripts correlated with high grade squamous intraepithelial lesions, statistically significantly. There was statistically difference between colposcopic, histologic concordance comparing to mRNA E6/E7 HPV colposcopic histologic concordance (p < 0.001).
CONCLUSIONS: The presence of mRNA E6/E7 HR HPV may be assumed as specific marker of high grade cervical lesions. The combination of mRNA E6/E7 HR HPV ewith colposcopic evaluation increases the colposcopy concordanece with final histologic findings.


Hagemann AR, Wilkinson-Ryan I, Kuroki LM, Squires K
Discussion: 'Comparison of cervical cancer screening strategies,' by Cox et al.
Am J Obstet Gynecol. 2013; 208(3):e1-4 [PubMed]
In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research.


Ezechi OC, Gab-Okafor CV, Ostergren PO, Odberg Pettersson K
Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.
BMC Public Health. 2013; 13:46 [PubMed] Free Access to Full Article
BACKGROUND: The proven benefit of integrating cervical cancer screening programme into HIV care has led to its adoption as a standard of care. However this is not operational in most HIV clinics in Nigeria. Of the various reasons given for non-implementation, none is backed by scientific evidence. This study was conducted to assess the willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.
METHODS: A cross sectional study of HIV positive women attending a large HIV treatment centre in Lagos, Nigeria. Respondents were identified using stratified sampling method. A pretested questionnaire was used to obtain information by trained research assistants. Obtained information were coded and managed using SPSS for windows version 19. Multivariate logistic regression model was used to determine independent predictor for acceptance of cervical cancer screening.
RESULTS: Of the 1517 respondents that returned completed questionnaires, 853 (56.2%) were aware of cervical cancer. Though previous cervical cancer screening was low at 9.4%, 79.8% (1210) accepted to take the test. Cost of the test (35.2%) and religious denial (14.0%) were the most common reasons given for refusal to take the test. After controlling for confounding variables in a multivariate logistic regression model, having a tertiary education (OR = 1.4; 95% CI: 1.03-1.84), no living child (OR: 1.5; 95% CI: 1.1-2.0), recent HIV diagnosis (OR: 1.5; 95% CI: 1.1-2.0) and being aware of cervical cancer (OR: 1.5; 95% CI: 1.2-2.0) retained independent association with acceptance to screen for cervical cancer.
CONCLUSIONS: The study shows that HIV positive women in our environment are willing to screen for cervical cancer and that the integration of reproductive health service into existing HIV programmes will strengthen rather than disrupt the services.


Gonzales KL, Harding AK, Lambert WE, et al.
Perceived experiences of discrimination in health care: a barrier for cancer screening among American Indian women with type 2 diabetes.
Womens Health Issues. 2013; 23(1):e61-7 [PubMed] Article available free on PMC after 01/01/2014
PURPOSE: Breast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes.
METHODS: Data were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors.
FINDINGS: Substantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination.
CONCLUSIONS: Among AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.


Su SY, Huang JY, Ho CC, Liaw YP
Evidence for cervical cancer mortality with screening program in Taiwan, 1981-2010: age-period-cohort model.
BMC Public Health. 2013; 13:13 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Cervical cancer is the most common cancer experienced by women worldwide; however, screening techniques are very effective for reducing the risk of death. The national cervical cancer screening program was implemented in Taiwan in 1995. The objective of this study was to examine and provide evidence of the cervical cancer mortality trends for the periods before and after the screening program was implemented.
METHODS: Data from 1981 to 2010 of the causes of death registered were obtained from the Department of Health, Taiwan. Age-standardized mortality rates, age-specific rates, and age-period-cohort models that employed the sequential method were used to assess temporal changes that occurred between 1981 and 2010, with 1995 used as the separating year.
RESULTS: The results showed that for both time periods of 1981 to 1995 and 1996 to 2010, age and period had significant effects, whereas the birth cohort effects were insignificant. For patients between 80 and 84 years of age, the mortality rate for 1981 to 1995 and 1996 to 2010 was 48.34 and 68.08. The cervical cancer mortality rate for 1996 to 2010 was 1.0 for patients between 75 and 79 years of age and 1.4 for patients between 80 and 84 years of age compared to that for 1981 to 1995. Regarding the period effect, the mortality trend decreased 2-fold from 1996 to 2010.
CONCLUSIONS: The results of this study indicate a decline in cervical cancer mortality trends after the screening program involving Papanicolaou tests was implemented in 1995. However, the positive effects of the screening program were not observed in elderly women because of treatment delays during the initial implementation of the screening program.



Cervical cancer screening among women aged 18-30 years - United States, 2000-2010.
MMWR Morb Mortal Wkly Rep. 2013; 61(51-52):1038-42 [PubMed]
Screening women for cervical cancer can save lives. However, among young women, cervical cancer is relatively rare, and too-frequent screening can lead to high costs and adverse events associated with overtreatment. Before 2012, cervical cancer screening guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and U.S. Preventive Services Task Force (USPSTF) differed on age to start and how often to get screened for cervical cancer. In 2012, however, all three organizations recommended that 1) screening by Papanicolau (Pap) test should not be used for women aged <21 years, regardless of initiation of sexual activity, and 2) a screening interval of 3 years should be maintained for women aged 21-30 years. ACS and ACOG explicitly recommend against yearly screening. To assess trends in Pap testing before the new guidelines were introduced, CDC analyzed 2000-2010 data from the Behavioral Risk Factor Surveillance System (BRFSS) for women aged 18-30 years. CDC found that, among women aged 18-21 years, the percentage reporting never having been screened increased from 26.3% in 2000 to 47.5% in 2010, and the proportion reporting having had a Pap test in the past 12 months decreased from 65.0% to 41.5%. Among those aged 22-30 years, the proportion reporting having had a Pap test within the preceding 12 months decreased from 78.1% to 67.0%. These findings showed that Pap testing practices for young women have been moving toward the latest guidelines. However, the data also showed a concerning trend: among women aged 22-30 years, who should be screened every 3 years, the proportion who reported never having had a Pap test increased from 6.6% to 9.0%. More effort is needed to promote acceptance of the latest evidence-based recommendations so that all women receive the maximal benefits of cervical cancer screening.


Kahesa C, Kjaer S, Mwaiselage J, et al.
Determinants of acceptance of cervical cancer screening in Dar es Salaam, Tanzania.
BMC Public Health. 2012; 12:1093 [PubMed] Article available free on PMC after 01/01/2014
OBJECTIVE: To describe how demographic characteristics and knowledge of cervical cancer influence screening acceptance among women living in Dar es Salaam, Tanzania.
METHODS: Multistage cluster sampling was carried out in 45 randomly selected streets in Dar es Salaam. Women between the ages of 25-59 who lived in the sampled streets were invited to a cervical cancer screening; 804 women accepted and 313 rejected the invitation. Information on demographic characteristics and knowledge of cervical cancer were obtained through structured questionnaire interviews.
RESULTS: Women aged 35-44 and women aged 45-59 had increased ORs of 3.52 and 7.09, respectively, for accepting screening. Increased accepting rates were also found among single women (OR 2.43) and among women who had attended primary or secondary school (ORs of 1.81 and 1.94). Women who had 0-2 children were also more prone to accept screening in comparison with women who had five or more children (OR 3.21). Finally, knowledge of cervical cancer and awareness of the existing screening program were also associated with increased acceptance rates (ORs of 5.90 and 4.20).
CONCLUSION: There are identifiable subgroups where cervical cancer screening can be increased in Dar es Salaam. Special attention should be paid to women of low education and women of high parity. In addition, knowledge and awareness raising campaigns that goes hand in hand with culturally acceptable screening services will likely lead to an increased uptake of cervical cancer screening.


Kahesa C, Kjaer SK, Ngoma T, et al.
Risk factors for VIA positivity and determinants of screening attendances in Dar es Salaam, Tanzania.
BMC Public Health. 2012; 12:1055 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Tanzania is among the countries in the world where the cervical cancer incidence is estimated to be highest. Acknowledging an increase in the burden of cervical cancer, VIA was implemented as a regional cervical cancer screening strategy in Tanzania in 2002. With the aim of describing risk factors for VIA positivity and determinants of screening attendances in Tanzania, this paper present the results from a comparative analysis performed among women who are reached and not reached by the screening program".
METHODS: 14 107 women aged 25-59 enrolled in a cervical cancer screening program in Dar es Salaam in the period 2002 - 2008. The women underwent VIA examination and took part in a structured questionnaire interview. Socioeconomic characteristics, sexual behavior, HIV status and high-risk (HR) HPV infection were determined in a subpopulation of 890 who participated and 845 who did not participate in the screening.
RESULTS: Being widowed/separated OR=1.41 (95% CI: 1.17-1.66), of high parity OR=3.19 (95% CI: 1.84-5.48) of low education OR= 4.30 (95% CI: 3.50-5.31) and married at a young age OR=2.17 (95% CI: 1.37-3.07) were associated with being VIA positive. Women who participated in the screening were more likely to be HIV positive OR=1.59 (95% CI. 1.14-2.25) in comparison with women who had never attended screening, while no difference was found in the prevalence of HR-HPV infection among women who had attended screening and women who had not attended screening.
CONCLUSION: Women who are widowed/separated, of high parity, of low education and married at a young age are more likely to be VIA positive and thus at risk of developing cervical cancer. The study further documents that a referral linkage between the HIV care and treatment program and the cervical cancer screening program is in place in the setting studied, where HIV positive were more likely to participate in the cervical cancer screening program than HIV negative women.


Daley E, Perrin K, Vamos C, et al.
Confusion about Pap smears: lack of knowledge among high-risk women.
J Womens Health (Larchmt). 2013; 22(1):67-74 [PubMed]
BACKGROUND: The impact of the Papanicolaou (Pap) smear on the prevention of cervical cancer is one of the greatest public health success stories. However, it is not clear if women understand the purpose of the Pap smear despite recent advancements and national attention over cervical cancer prevention. The purpose of this study was to examine Pap smear knowledge among three high-risk populations at different points in time.
METHODS: Women from three separate human papillomavirus (HPV) psychosocial studies completed surveys assessing Pap smear knowledge: (1) HPV-positive women (prevaccine population in 2005-2006, n=154, mean age 23.5), (2) college women (postvaccine population in 2008, n=276, mean age 18.9), and (3) minority college women (postvaccine population in 2011, n=711, mean age 23.3). Frequencies and logistic regression were employed to examine associations between demographic factors and accurate knowledge of Pap smear testing within each study.
RESULTS: Approximately one quarter of participants across all three samples did not know that the Pap smear is a test for cervical cancer. Participants also incorrectly believed that the Pap smear tests for HPV (82%-91%), vaginal infections (76%-92%), yeast infections (65%-86%), gonorrhea (55%-81%), herpes (53%-80%), HIV/AIDS (22%-59%), and pregnancy (17%-38%). Among all three studies, older age was the only factor significant with higher Pap knowledge. Higher HPV knowledge scores were significantly associated with higher Pap knowledge in studies 2 and 3 only.
CONCLUSIONS: Knowledge about the purpose of the Pap smear remains low. Findings underscore the significant need for clear and consistent messages among high-risk women regarding the prevention of cervical cancer and other reproductive health conditions.


Cuzick J, Bergeron C, von Knebel Doeberitz M, et al.
New technologies and procedures for cervical cancer screening.
Vaccine. 2012; 30 Suppl 5:F107-16 [PubMed]
The clearly higher sensitivity and reproducibility of human papillomavirus (HPV) DNA testing for high-grade cervical intraepithelial neoplasia (CIN) has led to widespread calls to introduce it as the primary screening test. The main concern has been its lower specificity, due to the fact that it cannot separate transient from persistent infections, and only the latter are associated with an increased risk of high-grade CIN and cancer. Thus, even proponents of HPV testing generally only recommend it for women over the age of 30 years (or in some cases 35 years). If HPV testing is to reach its full potential, new approaches with better specificity are needed, either as triage tests for HPV positive women or, if the high sensitivity of HPV DNA testing can be maintained, as alternate primary screening modalities. Approaches that may useful in this regard, especially as triage tests, include HPV typing, methylation (and consequent silencing) of host and viral genes, and new cytologic methods, such as p16(INK4a) staining, which attempt to identify proliferating cells. At an earlier stage of development are direct methods based on detection of HPV E6 or E7 proteins. Recent progress and current status of these methods is discussed in this chapter. The current status of visual inspection (VIA and VILI) methods is also surveyed and progress on self-sampling is reviewed. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.


Cox JT, Castle PE, Behrens CM, et al.
Comparison of cervical cancer screening strategies incorporating different combinations of cytology, HPV testing, and genotyping for HPV 16/18: results from the ATHENA HPV study.
Am J Obstet Gynecol. 2013; 208(3):184.e1-184.e11 [PubMed]
OBJECTIVE: The objective of the study was to compare 9 cervical cancer screening strategies to the current screening standard (cytology with human papillomavirus [HPV] triage of atypical squamous cells of undetermined significance) for the detection of high-grade cervical disease.
STUDY DESIGN: Women (n = 34,254) aged 30 years or older from the Addressing the Need for Advanced HPV Diagnostics (ATHENA) study underwent screening with cytology and HPV testing with simultaneous HPV16/18 genotyping; those with atypical squamous cells of undetermined significance cytology or greater or HPV-positive status were referred for colposcopy.
RESULTS: In general, screening strategies that offered greater sensitivity also required more referral to colposcopy. HPV testing was more sensitive than cytology for detection of cervical intraepithelial neoplasia grade 2 or greater, but strategies that depended on cytology for triage of HPV-positive women decreased this sensitivity. Various strategies of cotesting with cytology increased sensitivity but did so by increasing testing. Strategies that included integrated HPV16/18 testing provided more efficient referral to colposcopy.
CONCLUSION: Strategies that maximize detection of women at greatest risk of cervical intraepithelial neoplasia grade 3 or greater by immediate referral to colposcopy, with follow-up testing of women at intermediate risk, maximize the benefits of cervical cancer screening while decreasing the potential harm. Incorporating screening with HPV and triage of HPV-positive women by a combination of genotyping for HPV16/18 and cytology provided a good balance between maximizing sensitivity (benefit) and specificity by limiting the number of colposcopies (potential harm).


Ogilvie GS, Krajden M, van Niekerk DJ, et al.
Primary cervical cancer screening with HPV testing compared with liquid-based cytology: results of round 1 of a randomised controlled trial -- the HPV FOCAL Study.
Br J Cancer. 2012; 107(12):1917-24 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Round 1 data of human papillomavirus (HPV) FOCAL, a three-arm, randomised trial, which aims to establish the efficacy of HPV DNA testing as a primary screen for cervical cancer, are presented.
METHODS: The three arms are: Control arm - liquid based cytology with atypical squamous cells of unknown significance (ASC-US) triage with hrHPV testing; Intervention Arm - hrHPV at entry with liquid-based cytology (LBC) triage of hrHPV positives, with exit screen at 4 years; Safety check arm - hrHPV at entry with LBC triage of hrHPV positives with exit screen at 2 years.
RESULTS: A total of 6154 women were randomised to the control arm and 12 494 to the HPV arms (intervention and safety check). In the HPV arm, the baseline cervical intraepithelial neoplasia (CIN)2+ and CIN3+ rate was 9.2/1000 (95%CI; 7.4, 10.9) and 4.8/1000 (95%CI; 3.6, 6.1), which increased to 16.1/1000 (95%CI 13.2, 18.9) for CIN2+ and to 8.0/1000 (95%CI; 5.9, 10.0) for CIN3+ after subsequent screening of HPV-DNA-positive/cytology-negative women. Detection rate in the control arm remained unchanged after subsequent screening of ASC-US-positive/hrHPV DNA-negative women at 11.0/1000 for CIN2+ and 5.0/1000 for CIN3+.
CONCLUSION: After subsequent screening of women who were either hrHPV positive/cytology negative or ASC-US positive/HPV negative, women randomised to the HPV arms had increased CIN2+ detection compared with women randomised to the cytology arm.


Akinyemiju TF
Socio-economic and health access determinants of breast and cervical cancer screening in low-income countries: analysis of the World Health Survey.
PLoS One. 2012; 7(11):e48834 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Breast and Cervical cancer are the two most common cancers among women in developing countries. Regular screening is the most effective way of ensuring that these cancers are detected at early stages; however few studies have assessed factors that predict cancer screening in developing countries.
PURPOSE: To assess the influence of household socio-economic status (SES), healthcare access and country level characteristics on breast and cervical cancer screening among women in developing countries.
METHODS: Women ages 18-69 years (cervical cancer screening) and 40-69 years (breast cancer screening) from 15 developing countries who participated in the 2003 World Health Survey provided data for this study. Household SES and healthcare access was assessed based on self-reported survey responses. SAS survey procedures (SAS, Version 9.2) were used to assess determinants of breast and cervical cancer screening in separate models.
RESULTS: 4.1% of women ages 18-69 years had received cervical cancer screening in the past three years, while only 2.2% of women ages 40-69 years had received breast cancer screening in the past 5 years in developing countries. Cancer screening rates varied by country; cervical cancer screening ranged from 1.1% in Bangladesh to 57.6% in Congo and breast cancer screening ranged from 0% in Mali to 26% in Congo. Significant determinants of cancer screening were household SES, rural residence, country health expenditure (as a percent of GDP) as well as healthcare access.
DISCUSSION: A lot more needs to be done to improve screening rates for breast and cervical cancer in developing countries, such as increasing health expenditure (especially in rural areas), applying the increased funds towards the provision of more, better educated health providers as well as improved infrastructure.


Uygur D, Guler T, Yayci E, et al.
Association of speculum lubrication with pain and Papanicolaou test accuracy.
J Am Board Fam Med. 2012 Nov-Dec; 25(6):798-804 [PubMed]
PURPOSE: To determine the effects of lubrication of the vaginal speculum before insertion during a Papanicolaou test on perceived pain and quality of the cytology specimen.
METHODS: Four hundred eligible women participating in cervical cancer screening and an early detection program were randomized with respect to lubricant gel use before speculum insertion. Perceived pain during speculum insertion and cytology results were assessed in study groups.
RESULTS: The mean age of the patients was 45.7 years (range, 23-77 years). Pain score of the NO GEL group was significantly higher than that of the GEL group (2.3 and 1.6, respectively; P < .05). For premenopausal women, lubricant gel use significantly reduced the pain scores of the participants (P < .05). Cytological interpretations of the Papanicolaou test specimens were comparable among all groups.
CONCLUSIONS: During the collection of Papanicolaou test specimens, lubrication of the vaginal speculum with a small amount of K-Y Jelly (a water-soluble lubricant gel) decreases the pain associated with insertion of the vaginal speculum among postmenopausal women without obscuring the cytological interpretation of conventional or liquid-based cytology. In women of reproductive age, lubrication of the speculum with K-Y Jelly does not cause a meaningful effect with respect to perceived pain.


Schmeler KM
Preventing cervical cancer globally.
Cancer Prev Res (Phila). 2012; 5(11):1257-9 [PubMed]
Cervical cancer is one of the leading causes of cancer and cancer-related deaths among women worldwide. More than 85% of cases and deaths occur in the developing world where the availability of effective screening is limited. In this issue of the journal, Pierce and colleagues (beginning on page 1273) describe a novel technique using a high-resolution microendoscope (HRME) to diagnose cervical dysplasia. This perspective reviews the limitations of existing cervical cancer screening methods currently in use in low-resource settings and the potential for HRME imaging to contribute to cervical cancer prevention in the developing world.


Hoppenot C, Stampler K, Dunton C
Cervical cancer screening in high- and low-resource countries: implications and new developments.
Obstet Gynecol Surv. 2012; 67(10):658-67 [PubMed]
The implementation of cytology-based screening programs for precancerous lesions of the cervix has decreased the incidence of and mortality from cervical cancer in much of the developed world. Countries without the resources to install such frequent and laboratory-dependent screening programs have more and more options at their disposal. A screening program based on cytology analysis requires too much training, infrastructure, and repeated screening to be feasible. Visual inspection with acetic acid, often used throughout the world, is inexpensive and both sensitive and specific, but it lacks reproducibility. Although human papillomavirus (HPV) testing is too expensive for widespread use, its negative predictive value and sensitivity make it a promising method of screening. Utilizing HPV vaccines as a primary mode of prevention may not be financially feasible and does not obviate the need for screening. Cervical cancer has been considered an AIDS-defining illness, with HPV and HIV often coexisting, and screening methods have been shown to be as reliable for women with HIV as those without. Ultimately, the most clinically effective and cost-effective methods for reducing cervical cancer incidence are those that limit the number of visits that women are required to attend. Providing immediate cryotherapy for those with a positive screen, whether by visual inspection or HPV testing, is promising to have quite an impact, although the type of program implemented will depend on the needs and expectations of each country.


Vokó Z, Nagyjánosi L, Kaló Z
Cost-effectiveness of adding vaccination with the AS04-adjuvanted human papillomavirus 16/18 vaccine to cervical cancer screening in Hungary.
BMC Public Health. 2012; 12:924 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: The cervical cancer screening program implemented in Hungary to date has not been successful. Along with screening, vaccination is an effective intervention to prevent cervical cancer. The aim of this study was to assess the cost-effectiveness of adding vaccination with the human papillomavirus 16/18 vaccine to the current cervical cancer screening program in Hungary.
METHODS: We developed a cohort simulation state-transition Markov model to model the life course of 12-year-old girls. Eighty percent participation in the HPV vaccination program at 12 years of age was assumed. Transitional probabilities were estimated using data from the literature. Local data were used regarding screening participation rates, and the costs were estimated in US $. We applied the purchasing power parity exchange rate of 129 HUF/$ to the cost data. Only direct health care costs were considered. We used a 3.7% discount rate for both the cost and quality-adjusted life years (QALYs). The time horizon was 88 years.
RESULTS: Inclusion of HPV vaccination at age 12 in the cervical cancer prevention program was predicted to be cost-effective. The incremental cost-effectiveness ratio (ICER) of adding HPV vaccination to the current national cancer screening program was estimated to be 27 588 $/QALY. The results were sensitive to the price of the vaccine, the discount rate, the screening participation rate and whether herd immunity was taken into account.
CONCLUSIONS: Our modeling analysis showed that the vaccination of 12-year-old adolescent girls against cervical cancer with the AS04-adjuvanted human papillomavirus 16/18 vaccine would be a cost-effective strategy to prevent cervical cancer in Hungary.


Levy AR, Bruen BK, Ku L
Health care reform and women's insurance coverage for breast and cervical cancer screening.
Prev Chronic Dis. 2012; 9:E159 [PubMed] Article available free on PMC after 01/01/2014
INTRODUCTION: The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services.
METHODS: We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services.
RESULTS: Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for NBCCEDP cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care.
CONCLUSION: Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.


Isaac R, Finkel M, Olver I, et al.
Translating evidence into practice in low resource settings: cervical cancer screening tests are only part of the solution in rural India.
Asian Pac J Cancer Prev. 2012; 13(8):4169-72 [PubMed]
BACKGROUND: The majority of women in rural India have poor or no access to cervical cancer screening services, although one-quarter of all cervical cancers in the world occur there. Several large trials have proven the efficacy of low-tech cervical cancer screening methods in the Indian context but none have documented the necessary components and processes of implementing this evidence in a low-resource setting.
METHODS: This paper discusses a feasible model of implementation of cervical cancer screening programme in low-resource settings developed through a pilot research project carried out in rural Tamilnadu, India. The programme used visual inspection of cervix after acetic acid application (VIA) as a screening tool, nurses in the primary care centres as the primary screeners and peer educators within Self-Help Women groups to raise community awareness.
RESULTS: The uptake of screening was initially low despite the access to a screening programme. However, the programme witnessed an incremental increase in the number of women accessing screening with increasing community awareness.
CONCLUSIONS: The investigators recommend 4 key components to programme implementation in low-resource setting: 1) Evidence-based, cost-effective test and treatment available within the reach of the community; 2) Appropriate referral pathways; 3) Skilled health workers and necessary equipment; and 4) Optimisation of health literacy, beliefs, attitudes of the community.


Sasieni P, Castanon A
Dramatic increase in cervical cancer registrations in young women in 2009 in England unlikely to be due to the new policy not to screen women aged 20-24.
J Med Screen. 2012; 19(3):127-32 [PubMed]
OBJECTIVE: To explore whether the 17% increase in cervical cancer in England in 2009 was due to the change in cervical screening policy.
METHODS: Trends in incidence of cervical cancer and of cervical intraepithelial neoplasia grade 3 (CIN3) were analysed for England, Wales and Scotland. Invasive cervical cancer data on 4079 cancers in women aged 20-39 diagnosed between April 2007 and August 2011 in England were analysed by single year of age.
RESULTS: In England there was a 38% (95% confidence intervals [CI] 18-62%) increase in cervical cancer incidence rates in women aged 25-29 in 2009 relative to 2008, and a 30% (11-51%) increase in women aged 35-39. Compared rates in 2010 are similar to those in 2008. The average increase between 2000 and 2010 in women aged 25-29 was no greater in England than in Scotland and Wales (relative risk 0.98, 95% CI 0.69-1.39). In England there has been a gradual increase in CIN3 (particularly for ages 25-29) since 2003, with a more dramatic increase in 2009, but a fall in 2010. Audit data showed an increase in cancers diagnosed at age 25 in 2009/2010 and 2010/2011 (P ≤ 0.0004). No increase was observed at age 26. For ages 27-29 an increase in cancer was observed for 2008/2009-2009/2010 when compared with 2007/2008-2010/2011 (P < 0.00001), but linear trends were not significant.
CONCLUSIONS: The increase in cervical cancer in England in 2009 cannot be attributed to the lack of screening of women aged 20-24, or to a general decrease in the coverage or quality of cervical screening.


Elit L, Saskin R, Raut R, et al.
Sociodemographic factors associated with cervical cancer screening coverage and follow-up of high grade abnormal results in a population-based cohort.
Gynecol Oncol. 2013; 128(1):95-100 [PubMed]
INTRODUCTION: A cervical cytology based screening program is effective if there is regular screening of the 'at risk' population and close follow-up of those labeled abnormal.
METHODS: This is a population cohort study of women between 20-69 year old who were eligible in Ontario from 2008-2010. We used administrative data to evaluate the rates of cervical cancer screening and follow-up of high grade Pap tests. Variation in cervical cytology coverage and follow-up of high grade abnormal results are associated with age, area level income and health region. Multivariate logistic regression was used to identify independent factors associated with screening and followup.
RESULTS: 3.7million women were eligible for screening of which 72% had a Pap smear in the prior 3years. These rates varied by age, income and region (p<0.0001). Women residing in the lowest income neighborhoods were half as likely to be screened (p<0.0001). 83% of those with an high grade intraepithelial lesion Pap test result had follow-up with colposcopy or treatment within 6months and this varied by year, age, income and region (p<0.0001).
CONCLUSIONS: Despite universal health coverage, cervical cancer screening rates are suboptimal with older and low income women being at greatest risk. Follow-up among women with high grade abnormal tests is mediocre at 3months and acceptable at 6months. Novel models of cervical cancer screening program implementation are needed to address these inadequacies.


Depuydt CE, Benoy IH, Beert JF, et al.
Clinical validation of a type-specific real-time quantitative human papillomavirus PCR against the performance of hybrid capture 2 for the purpose of cervical cancer screening.
J Clin Microbiol. 2012; 50(12):4073-7 [PubMed] Article available free on PMC after 01/06/2013
To be acceptable for use in cervical cancer screening, a new assay that detects DNA of high-risk human papillomavirus (hrHPV) types must demonstrate high reproducibility and performance not inferior to that of a clinically validated HPV test. In the present study, a real-time quantitative PCR (qPCR) assay targeting the E6 and E7 genes of hrHPV was compared with Hybrid Capture 2 (hc2) in a Belgian cervical cancer screening setting. In women >30 years old, the sensitivity and specificity for intraepithelial neoplasias of grade 2 or worse (93 cases of cervical intraepithelial neoplasias of grade 2 or worse (CIN2+) and 1,207 cases of no CIN or CIN1) were 93.6% and 95.6%, respectively, and those of hc2 were 83.9% and 94.5%, respectively {relative sensitivity of qPCR/hc2 = 1.12 [95% confidence interval (CI), 1.01 to 1.23]; relative specificity = 1.01 [95% CI, 0.99 to 1.03]}. A score test showed that the sensitivity (P < 0.0001) and specificity (P < 0.0001) of the qPCR assay were not inferior to those of hc2 at the required thresholds of 90% and 98%, respectively. The overall agreement of hrHPV positivity between the two runs of the qPCR tests was 98.7% (95% CI, 97.5 to 99.4%), with a kappa value of 0.96 (95% CI, 0.83 to 1.00). The qPCR assay used in this study can be considered a reliable HPV assay that fulfills the clinical validation criteria defined for use in cervical cancer screening.


Markossian TW, Darnell JS, Calhoun EA
Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program.
Cancer Epidemiol Biomarkers Prev. 2012; 21(10):1691-700 [PubMed] Article available free on PMC after 01/10/2013
BACKGROUND: We evaluated the efficacy of a Chicago-based cancer patient navigation program developed to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution.
METHODS: Women with an abnormal breast (n = 352) or cervical (n = 545) cancer screening test were recruited for the quasi-experimental study. Navigation subjects originated from five federally qualified health center sites and one safety net hospital. Records-based concurrent control subjects were selected from 20 sites. Control sites had similar characteristics to the navigated sites in terms of patient volume, racial/ethnic composition, and payor mix. Mixed-effects logistic regression and Cox proportional hazard regression analyses were conducted to compare navigation and control patients reaching diagnostic resolution by 60 days and time to resolution, adjusting for demographic covariates and site.
RESULTS: Compared with controls, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, CI = 1.20-2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, CI = 1.75-3.06), with no difference before 30 days (aHR = 1.42, CI = 0.83-2.43). Variables significantly associated with longer time to resolution for breast cancer screening abnormalities were being older, never partnered, abnormal mammogram and BI-RADS 3, and being younger and Black for cervical abnormalities.
CONCLUSIONS: Patient navigation reduces time from abnormal cancer finding to definitive diagnosis in underserved women.
IMPACT: Results support efforts to use patient navigation as a strategy to reduce cancer disparities among socioeconomically disadvantaged women.


Battaglia TA, Bak SM, Heeren T, et al.
Boston Patient Navigation Research Program: the impact of navigation on time to diagnostic resolution after abnormal cancer screening.
Cancer Epidemiol Biomarkers Prev. 2012; 21(10):1645-54 [PubMed] Article available free on PMC after 01/10/2013
BACKGROUND: There is a need for controlled studies to assess the impact of patient navigation in vulnerable cancer populations.
METHODS: Boston Patient Navigation Research Program conducted a quasi-experimental patient navigation intervention across six federally qualified inner-city community health centers, three assigned to a breast cancer navigation intervention and three assigned to a cervical cancer navigation intervention; each group then served as the control for the other. Eligible women had an abnormal breast or cervical cancer screening test conducted at one of the participating health centers during a baseline (2004-2005) or intervention period (2007-2008). Kaplan-Meier survival curves and proportional hazards regression examined the effect of patient navigation on time to definitive diagnosis, adjusting for covariates, clustering by clinic and differences between the baseline and intervention period.
RESULTS: We enrolled 997 subjects in the baseline period and 3,041 subjects during the intervention period, of whom 1,497 were in the navigated arm, and 1,544 in the control arm. There was a significant decrease in time to diagnosis for subjects in the navigated group compared with controls among those with a cervical screening abnormality [aHR 1.46; 95% confidence interval (CI), 1.1-1.9]; and among those with a breast cancer screening abnormality that resolved after 60 days (aHR 1.40; 95% CI, 1.1-1.9), with no differences before 60 days.
CONCLUSIONS: This study documents a benefit of patient navigation on time to diagnosis among a racially/ethnically diverse inner city population.
IMPACT: Patient navigation may address cancer health disparities by reducing time to diagnosis following an abnormal cancer-screening event.


Gong JM, Shen Y, He YX, et al.
New technology for cervical cancer screening.
Int J Gynecol Cancer. 2012; 22(9):1564-9 [PubMed]
BACKGROUND: Cervical cancer is the second most common cancer among women worldwide. With the introduction of organized cervical cytological screening programs, the incidence of cervical cancer has been dramatically reduced.
OBJECTIVES: This study aimed to determine the new technology that can potentially afford unique advantages for cervical cancer screening.
METHODS: Cervical specimens collected in PreservCyt were processed for ThinPrep cytological test, the new technology test and human papillomavirus detection.
RESULTS: The concordance between the new technology and ThinPrep cytological test was 96.34%, with 931 cases positive and 148 cases negative with both tests (κ = 0.857). The sensitivity and the specificity of the new technology were 99.04% (931/940) and 82.22% (148/180), respectively. Youden index was 0.81. The positive predictive value and the negative predictive value were 96.68% (931/963) and 94.27% (148/157), respectively. In the 124 positive cases of the new technology, human papillomavirus DNA test was positive in 109 cases (87.9%) and negative in 15 cases (12.1%). Compared to the histopathological diagnosis, the sensitivity and the negative predictive value of the new technology were 98.57% (69/70) and 95.45% (21/22), respectively.
CONCLUSIONS: The screening design will enable evaluation of several competing screening technologies in reducing the incidence of and mortality from cervical cancer. In particular, if the new technology is used as the screening test, it can be a quick screening test and does not depend on the subjective judgment of the doctors. As such, it could potentially afford unique advantages for screening.


Quinn MK, Bubi TC, Pierce MC, et al.
High-resolution microendoscopy for the detection of cervical neoplasia in low-resource settings.
PLoS One. 2012; 7(9):e44924 [PubMed] Article available free on PMC after 01/10/2013
Cervical cancer is the second leading cause of cancer death among women in developing countries. Developing countries often lack infrastructure, cytotechnologists, and pathologists necessary to implement current screening tools. Due to their low cost and ease of interpretation at the point-of-care, optical imaging technologies may serve as an appropriate solution for cervical cancer screening in low resource settings. We have developed a high-resolution optical imaging system, the High Resolution Microendoscope (HRME), which can be used to interrogate clinically suspicious areas with subcellular spatial resolution, revealing changes in nuclear to cytoplasmic area ratio. In this pilot study carried out at the women's clinic of Princess Marina Hospital in Botswana, 52 unique sites were imaged in 26 patients, and the results were compared to histopathology as a reference standard. Quantitative high resolution imaging achieved a sensitivity and specificity of 86% and 87%, respectively, in differentiating neoplastic (≥CIN 2) tissue from non-neoplastic tissue. These results suggest the potential promise of HRME to assist in the detection of cervical neoplasia in low-resource settings.


Williams-Brennan L, Gastaldo D, Cole DC, Paszat L
Social determinants of health associated with cervical cancer screening among women living in developing countries: a scoping review.
Arch Gynecol Obstet. 2012; 286(6):1487-505 [PubMed]
INTRODUCTION: Thousands of women living in many middle and low-income countries are unnecessarily dying from cervical cancer, partly due to limited screening coverage.
OBJECTIVES: To identify social determinants of health (SDH) associated with cervical screening for women living in middle and low-income countries, to inform responses to improve SDH and screening coverage, and to identify research gaps.
METHODS: A scoping literature review. We located original research articles on SDH associated with cervical cancer screening through bibliographic databases, supplemented by hand searching (n=166+4). Included were those conducted in middle and low-income countries and published in English, Portuguese and Spanish academic journals between January 2000 and June 2011 (n=37). Excluded were those from high-income countries or focusing on screening-diagnostic techniques or HPV vaccine. Narrative synthesis examined the results in relation to a SDH framework.
RESULTS: A number of factors influence access along the pathway to cervical cancer screening. Structural (cultural and societal values, socioeconomic position, ethnicity), intermediary (geographic location, health seeking behaviours, psychosocial factors, nature of the health system), and cross-cutting (social cohesion) SDH were all important. No single factor could entirely explain the observed cervical screening patterns.
CONCLUSION: Cervical cancer screening among women living in middle and low-income countries are influenced by the interaction among several different SDH. The majority of researchers studying cervical cancer screening focused on exploring single socio-demographic variables, which is typical of positivist, biomedical and epidemiological research. An inter-sectionality approach may provide a richer understanding of the complexities that influence women's pathways to cervical cancer screening and assist design of international programmes and policies from a social justice perspective.


Malila N, Leinonen M, Kotaniemi-Talonen L, et al.
The HPV test has similar sensitivity but more overdiagnosis than the Pap test--a randomised health services study on cervical cancer screening in Finland.
Int J Cancer. 2013; 132(9):2141-7 [PubMed]
We compared test sensitivity (in terms of prevented cancers) and overdiagnosis (in terms of non-progressive pre-invasive lesions) between the human papillomavirus test (HPV test, Hybrid Capture 2) and the traditional Pap test in routine screening for cervical cancer. The design was a randomised (1:1) health services study in Finland with intake between 2003 and 2007. We estimated sensitivity by the incidence method within one screening round. Overdiagnosis was based on the rate of cervical intraepithelial Grade 3 (CIN3) lesions diagnosed at screen and during the following interval. Out of 203,788 randomised women 132,298 attended (65% in both study arms) and 600,753 person-years accumulated among attenders up to the end of 2010. In all attenders, 34 invasive cervical cancers and 288 CIN3 lesions were diagnosed at screen or during the following interval. The interval cancer incidence was 2.5/10(5) person-years (sensitivity 0.87) and 1.4 (sensitivity 0.93) in the HPV arm and Pap test arm, respectively. The rate of CIN3 lesions was 57.1 and 38.8, respectively. In conclusion, sensitivity of HPV testing was similar to that of Pap testing but caused more overdiagnosis. Therefore, implementation of HPV testing needs to be reconsidered especially in countries with well organised programmes.


Wiedmeyer ML, Lofters A, Rashid M
Cervical cancer screening among vulnerable women: factors affecting guideline adherence at a community health centre in Toronto, Ont.
Can Fam Physician. 2012; 58(9):e521-6 [PubMed] Article available free on PMC after 01/10/2013
OBJECTIVE: To see if refugee women at a community health centre (CHC) in Toronto, Ont, are appropriately screened for cervical cancer and if there are any demographic characteristics that affect whether they are screened.
DESIGN: Chart review.
SETTING: A CHC in downtown Toronto.
PARTICIPANTS: A total of 357 eligible refugee women attending the CHC.
MAIN OUTCOME MEASURES: Papanicolaou test received or documented reason for no Pap test.
RESULTS: Ninety-two percent of women in the study sample were either appropriately screened for cervical cancer or had been approached for screening. Eighty percent of women were appropriately screened. Demographic variables including pregnancy, being uninsured, not speaking English, recent migration to Canada, and being a visible minority did not affect receipt of a Pap test after migration in multivariate analyses. Not speaking English was associated with a delay to receiving a first Pap test after migration.
CONCLUSION: The clients at our centre are demographically similar to women who are typically overlooked for Pap tests in the greater Toronto area. Despite belonging to a high-risk population, refugee women in this multidisciplinary CHC were screened for cervical cancer at a higher rate than the local population.


Ghosh P, Gandhi G, Kochhar PK, et al.
Visual inspection of cervix with Lugol's iodine for early detection of premalignant & malignant lesions of cervix.
Indian J Med Res. 2012; 136(2):265-71 [PubMed] Article available free on PMC after 01/10/2013
BACKGROUND & OBJECTIVES: Majority of cases of cervical cancer are diagnosed at an advanced stage as cytology based screening programmes are ineffective in developing countries. The present study was done to look for carcinoma cervix and its precursors by visual inspection with Lugol's iodine (VILI), visual inspection with acetic acid (VIA) and Papanicolaou smear, and to analyse their sensitivity, specificity and predictive values using colposcopic directed biopsy as reference.
METHODS: In this cross-sectional study, 350 women were subjected to Pap smear, VIA, VILI and colposcopy. Cervical biopsy and endocervical curettage was taken from patients positive on any of these tests and in 10 per cent of negative cases.
RESULTS: The Pap smear was abnormal in 3.71 per cent, including (2.85%), low grade (LSIL) and (0.85%) high grade squamous intraepithelial lesions (HSIL). Thirteen per cent of the patients were found to be positive by VIA and 11.71 per cent were positive on VILI. Sensitivity for VIA, VILI and Pap smear was 89.5, 100 and 52.6 per cent, respectively, while the specificity for VIA, VILI and Pap smear was 91.2, 93.3 and 99.1 per cent, respectively.
INTERPRETATION & CONCLUSIONS: In low resource settings, cervical cancer screening by Pap smear can be replaced by visual methods like VILI, which has the highest sensitivity (100%) to detect any grade of dysplasia, and a good specificity (93.3%).


This page last updated: 22nd May 2013
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