Diama Bhadra Vale

Status of implementation and organization of cancer screening in The European Union Member States—Summary results from the second European screening report

The second report on the implementation status of cancer screening in European Union (EU) was published in 2017. The report described the implementation status, protocols and organization (updated till 2016) and invitation coverage (for index year 2013) of breast, cervical and colorectal cancer screening in the EU. Experts in screening programme monitoring (N = 80) from the EU Member States having access to requisite information in their respective countries provided data on breast, cervical and colorectal cancer screening through online questionnaires. Data was collected for screening performed in the framework of publicly mandated programmes only. Filled in questionnaires were received from 26 Member States for all three sites and from one Member State for breast cancer only. Substantial improvement in screening implementation using population‐based approach was documented. Among the age‐eligible women, 94.7% were residents of Member States implementing or planning population‐based breast cancer screening in 2016, compared to 91.6% in 2007. The corresponding figures for cervical cancer screening were 72.3 and 51.3% in 2016 and 2007, respectively. Most significant improvement was documented for colorectal cancer screening with roll‐out ongoing or completed in 17 Member States in 2016, compared to only five in 2007. So the access to population‐based screening increased to 72.4% of the age‐eligible populations in 2016 as opposed to only 42.6% in 2007. The invitation coverage was highly variable, ranging from 0.2–111% for breast cancer, 7.6–105% for cervical cancer and 1.8–127% for colorectal cancer in the target populations. In spite of the considerable progress, much work remains to be done to achieve optimal effectiveness. Continued monitoring, regular feedbacks and periodic reporting are needed to ensure the desired impacts of the programmes.

Avaliação do rastreamento do câncer do colo do útero na Estratégia Saúde da Família no Município de Amparo, São Paulo, Brasil

Uterine cervical cancer mortality has not been declining. The territorial distribution and registration of families in Brazils Family Health Strategy help identify women that have performed a Pap smear or that have not had one for more than three years. This study analyzed whether cervical cancer screening in Amparo, São Paulo State, Brazil, made progress in complying with the prevailing guidelines during the seven years of experience with the Strategy. The annual examination rate remained high, with a slight trend towards greater intervals between follow-up tests. Distribution of tests tended to increase in the 40-59-year age bracket and decrease in the over-60 age group, while annual coverage tended to decrease. The proportions of excess tests varied from 61.2% to 65.5%. Concluding, the upgrading of cervical cancer screening was slight, and did not change the opportunistic pattern of follow-up tests. Considering that community health agents can act to increase the coverage of these measures, it is essential to train them for this work.Uterine cervical cancer mortality has not been declining. The territorial distribution and registration of families in Brazil’s Family Health Strategy help identify women that have performed a Pap smear or that have not had one for more than three years. This study analyzed whether cervical cancer screening in Amparo, São Paulo State, Brazil, made progress in complying with the prevailing guidelines during the seven years of experience with the Strategy. The annual examination rate remained high, with a slight trend towards greater intervals between follow-up tests. Distribution of tests tended to increase in the 40-59year age bracket and decrease in the over-60 age group, while annual coverage tended to decrease. The proportions of excess tests varied from 61.2% to 65.5%. Concluding, the upgrading of cervical cancer screening was slight, and did not change the opportunistic pattern of follow-up tests. Considering that community health agents can act to increase the coverage of these measures, it is essential to train them for this work. Mass Screening; Uterine Cervical Neoplasms; Family Health Introdução O câncer do colo do útero é um importante problema de saúde pública, e sua incidência e mortalidade podem ser reduzidas por meio de programas de rastreamento efetivos 1. Idealmente, o rastreamento do colo do útero deveria seguir um conjunto de ações programadas, com população e periodicidade definidas, o que tem sido denominado de programa organizado 2. Todavia, é sabido que ainda predomina, em países como o Brasil, a realização de controles não relacionados com as normas estabelecidas, e sim com a procura ocasional dos serviços de saúde determinada por razões diversas que não o rastreamento do câncer do colo do útero. Essa modalidade tem sido designada de rastreamento oportunístico, e não tem sido eficiente em reduzir as taxas de incidência e mortalidade do câncer do colo do útero 2,3,4,5. O rastreamento oportunístico apresenta baixa cobertura, super-rastreia um pequeno grupo de mulheres e, portanto, é menos custo-efetivo 6,7. No Brasil, apesar de haver um programa de rastreamento do câncer do colo do útero, a taxa de mortalidade devido a esse câncer não tem reduzido 8. As normas preconizadas para o rastreamento desse tipo de câncer no país seguem a tendência universal de não incluir prioritariamente as mulheres com menos de 25 anos e as com mais de 60, sendo que o intervalo ideal entre os controles é trienal 9. ARTIGO ARTICLE Vale DBAP et al. 384 Cad. Saúde Pública, Rio de Janeiro, 26(2):383-390, fev, 2010 Estratégias que busquem alterar esse cenário devem incluir a sistematização de um programa organizado, objetivando aumentar a cobertura das faixas etárias recomendadas para o rastreamento 2,3. O Ministério da Saúde realizou em 2002-2003 um inquérito domiciliar que incluiu 15 capitais brasileiras e o Distrito Federal. Nesse estudo, a distribuição de mulheres de 25 a 59 anos que realizaram pelo menos um exame de Papanicolaou nos três anos anteriores à pesquisa variou de 32% no Rio de Janeiro a 63,4% em Manaus, na população usuária do Sistema Único de Saúde (SUS) 10. A Estratégia Saúde da Família (ESF) é um programa do sistema de saúde brasileiro que tem como objetivo reorientar o modelo assistencial. Ao incluir na sua prática a articulação entre a prevenção e a promoção da saúde, por meio da expansão e qualificação da atenção primária, gera um cenário favorável à reorganização do modo de rastreamento do câncer do colo do útero 11. Em comunidades com a ESF introduzida, espera-se que os agentes comunitários de saúde (ACS), por intermédio da adscrição da clientela, estabeleçam vínculo entre a equipe de referência e as famílias, objetivando uma maior resolubilidade da atenção. No contexto do rastreamento isso possibilitaria a identificação e busca ativa das pacientes sob risco e sem controles 11. Portanto, este estudo verificou se o rastreamento realizado no âmbito da ESF segue as recomendações do Ministério da Saúde. Os parâmetros analisados foram a periodicidade de realização dos exames, os grupos etários rastreados e a cobertura populacional do programa de rastreamento do câncer do colo do útero no Município de Amparo, Estado de São Paulo, que adota a ESF desde 1998.

High-grade squamous intraepithelial lesion in women aged <30 years has a prevalence pattern resembling low-grade squamous intraepithelial lesion.

Cervical cytology is the cervical cancer screening test for women aged <30 years because of the low specificity of human papillomavirus tests in this age group. The Bethesda System classifies cervical intraepithelial neoplasia grade 2 (CIN 2) and grade 3 (CIN 3) as high‐grade intraepithelial lesions (HSIL). In this study, the authors subclassified cytologic HSIL as suggestive of CIN 2 (HSIL‐CIN 2) or CIN 3 (HSIL‐CIN 3) and evaluated whether there was a correlation between these findings and age for screened and unscreened women.

17-Hydroxyprogesterone deficiency as a cause of sexual infantilism and arterial hypertension: Laboratory and molecular diagnosis – a case report

The differential diagnosis of hypertension associated with hypokalemia in infancy and adolescence should necessarily include deficiency of the 17α-hydroxylase enzyme, a rare form of congenital adrenal hyperplasia (CAH). In addition to hypertension, the classic syndrome caused by this deficiency is characterized by suppressed production of sex hormones and consequently sexual infantilism. Although rare (1% of all forms of CAH), there appears to be a higher incidence of this syndrome in some population groups. This is a case report on two sisters followed up at the Department of Obstetrics and Gynecology, School of Medicine, Universidade Estadual de Campinas (UNICAMP), who were both found to have the 46,XY genotype with homozygosis for W406R, exon 7 of the CYP17 gene (OMIM 202110). The condition was diagnosed only at puberty when hypergonadotropic hypogonadism resulted in sexual infantilism; however, arterial hypertension had been present since infancy and late diagnosis and lack of timely adequate treatment resulted in complications.

Secondary prevention of cervical cancer

Cervical cancer affects women in their reproductive ages. Screening is an important secondary prevention strategy. The long process of carcinogenic transformation from human papillomavirus (HPV) infection to invasive cancer provides ample opportunities to detect the disease at a stage when treatment is highly effective. Suitable screening tests are cytology, visual inspection after acetic acid application and HPV detection tests. Evidence of effectiveness of the tests to reduce cervical cancer mortality and the cost-effectiveness of screening programs have been demonstrated. Cervical intraepithelial neoplasia grade 2 and grade 3 are the high-grade cervical cancer precursors and need to be treated. Treatment is safe and effective with ablative or excisional techniques. The World Health Organization recommends screening women at least once in a lifetime between 30 and 49 years of age and ensuring effective treatment of the detected abnormalities. Combination of HPV vaccination and population-based screening will be instrumental in eliminating cervical cancer.

Protection against squamous cell carcinoma and cervical adenocarcinoma afforded by cervical cytology screening: a cross-sectional study.

Objective The objective of this study was to evaluate the impact of cervical cytology screening on the prevalence of cervical cytological results in women, as a function of age and test interval. Methods This is a cross-sectional study of cytology screening data of 2,002,472 tests obtained from previously screened women and 217,826 tests from unscreened women. The central cytopathology laboratory database was analyzed. The tests were collected for screening purposes from Campinas metropolitan region, Brazil. A prevalence ratio (PR) with a 95% confidence interval was calculated for the screened women, in relation to the unscreened women, and for different tests intervals. Protection afforded by screening (1-PR) was calculated. Results For high-grade squamous intraepithelial lesion, the PR was 0.97 (0.83–1.13) for women aged 20 years or younger and 0.99 (0.86–1.14) for women aged 20 to 24 years, decreasing significantly in women aged 25 to 29 years (PR, 0.63 [0.52–0.76]). The PR for squamous cell carcinoma, adenocarcinoma in situ (AIS), and invasive adenocarcinoma showed a significant reduction in all age groups older than 30 years. For the age group ranging from 30 to 59 years, protection for squamous cell carcinoma, AIS, and invasive adenocarcinoma was 83% or higher for screening intervals from 1 to 5 years. Protective effect was not demonstrated for screening intervals longer than 5 years for AIS and invasive adenocarcinoma. Conclusions Cytology screening is effective at preventing cytological high-grade squamous intraepithelial lesion, squamous cell carcinoma, AIS, and invasive adenocarcinoma. On the basis of cytological results, protection against AIS and invasive adenocarcinoma was observed with screening intervals shorter than 5 years. Cytological screening in women 25 years or younger should be critically evaluated.

High-grade squamous intraepithelial lesions in pregnant and non-pregnant women

OBJECTIVES To evaluate if the prevalence of cervical smear results varies between pregnant and non-pregnant women stratified by age group. STUDY DESIGN Observational analytical study with a total sample of 1,336,180 pregnant and non-pregnant women, aged between 20 and 34 years, who underwent cervical cancer screening in the Primary Health Care of the national health system in the area of Campinas in Brazil during the period of 2005-2009. The source is the information system for cervical cancer screening. Data collected on abnormal cervical smears were analyzed using the Chi-square test and Fishers exact test and the magnitude of the association between pregnancy and high-grade squamous epithelial lesions was analyzed by odds ratio (OR) and estimated values with confidence intervals (CI) of 95%. RESULTS 15,190 pregnant women and 395,961 non-pregnant women were analyzed and fulfilled the inclusion criteria. Regardless of age, no statistical differences were observed for high-grade squamous intraepithelial lesion prevalence (OR 0.90; CI 0.66-1.23). Taking into account the five-year age groups, however, low-grade squamous intraepithelial lesion was less prevalent in pregnant women aged 20-24 (OR 0.71; 0.54-0.95) and 25-29 years (OR 0.56; 0.35-0.89); also, atypical squamous cells of undetermined significance was more prevalent in non-pregnant women aged 25-29 years (OR 0.72; 0.54-0.97). CONCLUSION The study showed that the cytological prevalence of high-grade squamous intraepithelial lesion was similar in pregnant and non-pregnant women, regardless of age. The results indicate that there are no reasons for specific approaches to cervical cancer screening for pregnant women. The examination should be carried out only on pregnant women who have not been tested according to current recommendations.

Results of screening for cervical cancer among pregnant and non‐pregnant women in Brazil

To compare cervical cytology test results among pregnant and non‐pregnant women, and to assess associations with age, screening history, and onset of sexual intercourse.

Early Age at First Sexual Intercourse is Associated with Higher Prevalence of High-grade Squamous Intraepithelial Lesions (HSIL)

Objective To evaluate the association of age at first sexual intercourse with the results of the cervicovaginal cytology. Study Design Observational analytical study about the prevalence of altered cervicovaginal cytology results in women aged between 18 and 34 years from a densely populated area in Brazil, during 10 years. The patients were stratified into 2 categories according to their age at first sexual intercourse (13-16 years and 17-24 years). Results From the total of 2,505,154 exams, 898,921 tests were in accordance with the inclusion criteria. Considering women with 4 years or less from the first sexual intercourse as a reference, those with 5 to 9 years and 10 years or more showed a higher prevalence of high-grade squamous intraepithelial lesions (HSILs). Women with an earlier onset of sexual intercourse (13-16 years) showed higher prevalence ratios for atypical squamous cells (ASC), low-grade squamous intraepithelial lesion (LSIL) and HSIL. The prevalence ratio for HSIL adjusted by age at diagnosis and by age at first sexual intercourse was higher only for women with an earlier onset of sexual intercourse. Conclusions The age of first sexual intercourse could be a variable that might qualify the selection among young women who are really at a higher risk for HSIL.

Usefulness of vaginal cytology tests in women with previous hysterectomy for benign diseases: assessment of 53,891 tests.

OBJECTIVE To assess the value of vaginal screening cytology after hysterectomy for benign disease. METHODS This cross-sectional study used cytology audit data from 2,512,039 screening tests in the metropolitan region of Campinas from 2000 to 2012; the object was to compare the prevalence of abnormal tests in women who had undergone a hysterectomy for benign diseases (n=53,891) to that of women who had had no hysterectomy. Prevalence ratios (95% confidence intervals, 95% CI) were determined, and chi-square analysis, modified by the Cochrane-Armitage test for trend, was used to investigate the effects of age. RESULTS The prevalence of atypical squamous cells (ASC), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion or squamous-cell carcinoma (HSIL/SCC) was 0.13%, 0.04% and 0.03%, respectively, in women who had undergone hysterectomy, and 0.93%, 0.51% and 0.26% in women who had not undergone hysterectomy. The prevalence ratios for ASC, LSIL and HSIL/SCC were 0.14 (0.11-0.17), 0.08 (0.06-0.13) and 0.13 (0.08-0.20), respectively, in women with a hysterectomy versus those without. For HSIL/SCC, the prevalence ratios were 0.09 and 0.29, respectively, for women <50 or ≥50 years. The prevalence rates in women with a previous hysterectomy showed no significant variation with age. CONCLUSION The prevalence rates of ASC, LSIL and HSIL/SCC were significantly lower in women with a previous hysterectomy for benign disease compared with those observed in women with an intact uterine cervix. This study reinforces the view that there is no evidence that cytological screening is beneficial for women who have had a hysterectomy for benign disease.