James E. Parker

Cervical cancer control. A study of morbidity and mortality trends over a twenty‐one‐year period

Data from a 21‐year period are presented to evaluate the effects of a mass cytologic screening program on uterine cancer morbidity and mortality in Louisville, Jefferson County, Kentucky. The success of screening was greatest in the younger age groups. There was a fall‐off after age 45 years, especially in those age 60 years or older. Women at highest risk for cervical cancer, in the low socioeconomic quartile, had a better initial screening rate than the two middleincome quartiles, and had the highest rate of all women for subsequent rescreening. The greatest decrease in both morbidity and mortality was in women under the age of 50 years. Women age 30–39 and 50–59 years benefitted the most, as measured by mortality, with a decrease of 70.8 and 69.0%, respectively. There was no change in mortality rates for those age 70 years or older. Although there was individual benefit among the screenees with endometrial carcinoma, the average annual age‐adjusted rate increased from 13.2 to 15.3/100,000 women over the 21‐year period.

Cervix cancer death rates and mass cytologic screening.

Death rates for cervix cancer and total uterine cancer among women 20 years old and older have decreased significantly in Jefferson County, Ky., from 1953‐1967. Death rates have not changed significantly in Kentucky outside of Jefferson County during this time period. The average age at time of death from cervix cancer is 7.6 years greater for Jefferson County residents during the last 3 years of the study compared to the first 3 years. The only known factor which could account for these observations is a mass cytologic screening program for cervix cancer in Jefferson County; there was no such mass screening effort in the rest of the state.

Cervix cancer control in Louisville, Kentucky

The results of 12 years of mass cytologic screening of a community for protection from uterine cancer are reported, and the effects upon incidence rates of the various component cancers are analyzed. A preceding 3‐year period during which no screening was performed was used to calculate the expected rates. Total cancers of the uterus, including carcinoma in‐situ, had an average annual rate of 125.5 per 100,000 women 20 years of age and older during the 15‐year period. During the last 3‐year period, carcinoma of the cervix was diagnosed at an earlier stage, and the rates decreased by one third. Carcinoma in‐situ increased in proportion to screening activity. There was an increase in the rate for endometrial carcinoma. The greatest response to screening was in women under 50 years of age. This group showed the greatest decrease in rates and was, for the most part, diagnosed at an earlier stage of the disease. On the other hand, older women were less inclined to avail themselves of cytologic screening.

Carcinoma of the endometrium: A study of changing rates over a 15-year period

A 15‐year study of endometrial carcinoma in Louisville‐Jefferson County, Kentucky, revealed an increase of 26.3% in average yearly rates when the first 3 years, 1953‐1955, were compared with the last 3 years, 1965‐1967. An increase of 15.9% persisted when the rates were corrected for aging of the population; this was not statistically significant. Thus the mass cytologic screening program which had a beneficial effect on the rates for invasive cervix cancer, failed to have such an effect on endometrial carcinoma.

Control of cervix cancer in women of low income in a community.

A program to control cancer of the uterine cervix in women of a low‐income level in Louisville (Jefferson County), Kentucky over a 12‐year period is described. Initial satisfactory examinations were obtained on 37,209 women. Rescreenings at an interval of 1 to 12 years totaled 51,063 examinations. The population was equally divided between Negroes and Caucasians. Prevalence rates of cytologically detected cervix carcinoma were very high—3.79 per 1000 for invasive squamous carcinoma and 4.41 for carcinoma in situ. The first repeat examination based on patient years fell to 0.67 and 1.46 per 1000 women for these 2 lesions. The decrease continued through subsequent screenings. Stage I carcinoma increased to 63.93% of the total cases during the years of screening. We conclude from the data presented that mortality rates from cervix cancer will have to reflect the decrease in incidence and the increase in early diagnosed cases.

Microinvasive carcinoma of the uterine cervix: A long-term followup study of eighty cases.

One hundred and eleven patients with microinvasive carcinoma of the uterine cervix were studied over a 21‐year period. Thirty‐five cases of carcinoma in situ with questionable stromal invasion were excluded. Cases with pathologic examination of less than a cervical cone or the entire cervix were not accepted. The sole pathologic criterion for inclusion was unequivocal invasion to a depth of no more than 5.0 nm. Ninety‐one patients were followed for 5 years or until death, and 80 patients for 10 years or until death. One patient was lost to follow‐up at 5.5 years. The two deaths officially attributed to cervix cancer prior to 10 years were signed out by nonphysician assistant coroners. Available clinical evidence indicates that at least one of these patients, and probably both, did not die of cervix cancer. From these data, simple hysterectomy would seem to be the maximal treatment indicated. Since the prognosis of microinvasive carcinoma is similar to that of carcinoma in situ, it is suggested that such cases not be included when considering the end results of Stage I cervix cancer.

CERVICAL CELL STUDIES—A METHOD OF INCREASING PRODUCTION

The effectiveness of cervical cell studies for the detection of early asymptomatic cervical cancer, in either the early invasive or the preinvasive stage, has been well documented and is now generally accepted by the medical profession. The major problem at the present time, where large numbers of women are being screened by the cell study method, is the scarcity of trained technicians to perform the laborious task of screening the slides to eliminate the normal and pick out the abnormal slides for further study. The demand for such screeners greatly exceeds the supply and will do so for some time to come. In an effort to evaluate methods of increasing the productivity of available personnel, we decided to determine whether a single slide preparation would approach, in accuracy, the examination of two or more slides from each individual when the technique of visualization of the cervix and the direct endocervical