Early diagnosis of symptomatic gynecological cancer is likely to improve patient outcomes, including survival. The primary care practitioner has a key role to play in this-they must recognize the symptoms and signs of gynecological cancer and make prompt evidence-based decisions regarding further investigation and referral. However, this is often difficult as many of the symptoms of gynecological cancers are nonspecific and are more likely to be caused by benign rather than malignant disease. As primary care is generally the first point of patient contact, those working in this setting usually encounter cancer patients at an earlier, and possibly less symptomatic, stage than practitioners in secondary care. Despite these challenges, research has improved our understanding of the symptoms patients present to primary care with, and a range of tests and referral pathways now exist in the UK and other countries to aid early diagnosis. Primary care practitioners can also play a key role in gynecological cancer prevention. A significant proportion of gynecological cancer is preventable either through lifestyle changes such as weight loss, or, for cervical cancer, vaccination and/or engagement with screening programs. Primary care provides an excellent opportunity to discuss cancer risk with patients and to promote risk reduction strategies and lifestyle change. In this article, the first in a series discussing cancer detection in primary care, we concentrate on gynecological cancer and focus on the three most common forms that a primary care practitioner is likely to encounter: ovarian, endometrial, and cervical cancer. We outline key risk factors, briefly discuss prevention and screening strategies, and offer practical guidance on the recognition of symptoms and signs and the investigation and referral of women with suspected cancer. While this article is written from a UK primary care perspective, much of what is discussed will be of relevance to those working in other healthcare systems.

/pdf/recognizing-gynecological-cancer-in-primary-care-risk-55q2idv9uc.pdf

Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals.

Objective

To assess the sensitivity, the number needed to screen (NNS) and the positive predictive value (PPV) of cervical cytology for the diagnosis of cancer by age in a screening population.



Methods

A retrospective cohort of women with invasive cervical cancer nested within a census of cervical cytology. All (c. 8 million) women aged 20–64 years with cervical cytology (excluding tests after an earlier abnormality). From April 2007 to March 2010, 3372 women had cervical cancer diagnosed within 12 months of such cytology in England. The sensitivity of cervical cytology to cancer, NNS to detect one cancer and predictive values of cytology were calculated for various ’referral‘ thresholds. These were calculated for ages 20–24, 25–34, 35–49 and 50–64 years.



Results

The sensitivity of at least moderate dyskaryosis [equivalent to a high-grade squamous intraepithelial lesion (HSIL) or worse] for cancer of 89.4% [95% confidence interval (CI) 88.3–90.4%] in women offered screening was independent of age. At all ages, women with borderline-early recall or mild dyskaryosis on cytology (equivalent to ASC-US and LSIL, respectively, in the Bethesda system) had a similar risk of cervical cancer to the risk in all women tested. The PPV of severe dyskaryosis/?invasive and ?glandular neoplasia cytology (equivalent to squamous cell carcinoma and adenocarcinoma/adenocarcinoma in situ, respectively, in the Bethesda System) were 34% and 12%, respectively; the PPV of severe dyskaryosis (HSIL: severe dysplasia) was 4%. The NNS was lowest when the incidence of cervical cancer was highest, at ages 25–39 years, but the proportion of those with abnormal cytology who have cancer was also lowest in younger women.



Conclusions

The PPV of at least severe dyskaryosis (HSIL: severe dysplasia) for cancer was 4–10% of women aged 25–64 years, justifying a 2-week referral to colposcopy and demonstrating the importance of failsafe monitoring for such patients. The sensitivity of cytology for cervical cancer was excellent across all age groups.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/cyt.12259

Evaluating cytology for the detection of invasive cervical cancer

PurposeIn low- and middle-income countries like Nigeria, women present with advanced breast cancer at an earlier age. Given the limited resources, development of screening programs that parallel resource capabilities of low- and middle-income countries is imperative. The objective of this study was to evaluate the perceptions, practices, and barriers regarding clinical breast examination (CBE) screening in a low-income community in Nigeria.Materials and MethodsA cross-sectional survey of women age 40 years or older in Ife, Nigeria, using multistaged sampling was performed. Information on sociodemographics, knowledge of breast cancer, screening practices, and willingness to participate in CBE screening was obtained using an interviewer-administered questionnaire.ResultsA total of 1,169 women whose ages ranged from 40 to 86 years (mean age, 47.7 years; standard deviation, 8.79 years) were interviewed. The majority of women (94%) knew about breast cancer, whereas 27.5% knew someone who had had breast cancer,...

Developing a Breast Cancer Screening Program in Nigeria: Evaluating Current Practices, Perceptions, and Possible Barriers.

Importance Little is known about the long-term yield of high-grade cervical intraepithelial neoplasia (CIN) and the influence on biopsy and treatment rates of human papillomavirus (HPV) triage of cytology showing atypical squamous cells of undetermined significance (hereafter ASC-US cytology). Objective To examine 5-year outcomes after ASC-US cytology with vs without HPV testing. Design, Setting, and Participants In this observational study, all cervical cytology and HPV testing reports from January 1, 2007, to December 31, 2012, were obtained for women throughout New Mexico and linked to pathology reports. The dates of the analysis were May 4, 2015, to January 13, 2017. Main Outcomes and Measures Influence of HPV testing on disease yield, time to histologically confirmed disease, and biopsy or loop electrosurgical excision procedure rates. Results A total of 457 317 women (mean [SD] age, 39.8 [12.5] years) with a screening test were recorded between 2008 and 2012, and 20 677 (4.5%) of the first cytology results per woman were reported as ASC-US. CIN grade 3 or more severe (CIN3+) lesions were detected in 2.49% of women with HPV testing vs 2.15% of women without HPV testing (P = .23). Time to CIN3+ detection was much shorter in those with HPV testing vs those without testing (median, 103 vs 393 days;P  Conclusions and Relevance Human papillomavirus testing led to faster and more complete diagnosis of cervical disease, but 55.8% more biopsies and 20.0% more loop electrosurgical excision procedures were performed. In those tested, virtually all high-grade disease occurred in the 43.1% of women who were HPV positive, allowing clinical resources to be focused on women who need them most. These data provide essential information for cervical screening guidelines and public health policy.

/pdf/outcomes-in-women-with-cytology-showing-atypical-squamous-5jklcj1gml.pdf

Outcomes in Women With Cytology Showing Atypical Squamous Cells of Undetermined Significance With vs Without Human Papillomavirus Testing

Objective: To analyze the results of the last cytopathological report of patients with delayed Pap smear Methodology: Documentary, retrospective study with quantitative approach, conducted in the city of Redencao-CE, from April to September 2018 Were explored 660 medical records of women aged 25 to 64 years For analysis, measures of central tendency and absolute and relative frequencies were used Results: The number of women who had never had the Pap smear was 44,7%, and those who had been submitted but were delayed were 55,3% The presence of metaplastic cells was less frequent (38,6%) Among infectious agents, there was a prevalence of suggestive results of Gardnerella vaginalis and Mobiluncus (14,9%), Candida sp (3,9%) and Trichomonas vaginalis (1,1%) The reports indicated the presence of premalignant and malignant cellular alterations Conclusion: There are a large number of women with delayed Pap tests and a deficiency in the quality of the tests, indicated by the absence of metaplastic tissue This should motivate the active search of patients to interrupt the chain of transmission of Sexually Transmitted Infections and to treat cervical lesions early, reducing the chances of progression Descriptors: Uterine Cervical Neoplasms, Papanicolaou Test, Mass Screening, Primary Health Care, Nursing

/pdf/analise-dos-resultados-do-ultimo-laudo-citopatologico-de-2gpemyc1rk.pdf

Análise dos resultados do último laudo citopatológico de pacientes com Papanicolaou em atraso

ObjectivesMost non-screen-detected cervical cancers are advanced stage. We assess the potential for cytology to expedite diagnosis when used outside of routine call and recall screening for cervical cancer.MethodsTwo cohorts of women with cytology that did not appear to have been taken as part of routine screening, nested within a census of cervical cytology, in England between April 2007 and March 2010 were studied: 93,322 women aged 40–69 at first cytology, and 14,668 women aged ≥70. The diagnostic performance of high grade cervical squamous intraepithelial lesion (HSIL) or worse cytology was estimated. We also estimated case-fatality from stage distribution in women aged ≥66 with and without cytology in the year prior to diagnosis.ResultsThere were 259 cancers diagnosed in women aged 40–69 at first cytology, and 78 in women aged ≥70. The sensitivity of cytology ≥ HSIL for cancer was 89% and 83% respectively, and the number of women needed to test to identify one cancer was 404 (95% confidence interval ...

https://journals.sagepub.com/doi/pdf/10.1177/0969141315598174

Cervical cytology and the diagnosis of cervical cancer in older women

Background Cervical cancer in young women presents a diagnostic challenge because gynaecological symptoms are common but underlying disease is rare.

Aim To explore the potential for using cytology as a diagnostic aid for cervical cancer in young women.

Design and setting Retrospective review of primary care records and cytology data from the national cervical screening database and national audit of cervical cancers.

Method Four datasets of women aged 20–29 years in England were examined: primary care records and national screening data from an in-depth study of cervical cancers; cytology from the national audit of cervical cancers; whole-population cytology from the national screening database; and general-population primary care records from the Clinical Practice Research Datalink. The authors explored the sensitivity and positive predictive value (PPV) of symptomatic cytology (earliest <12 months before diagnosis) to cervical cancer.

Results The estimated prevalence of cervical cancer among symptomatic women was between 0.4% and 0.9%. The sensitivity of moderate dyskaryosis (high-grade squamous intraepithelial lesion [HSIL]) or worse in women aged 20–29 years was 90.9% to 96.2% across datasets, regardless of symptom status. The PPV was estimated to be between 10.0% and 30.0%. For women aged 20–24 years, the PPV of ‘?invasive squamous carcinoma’ was 25.4%, and 2.0% for severe or worse cytology.

Conclusion Cytology has value beyond screening, and could be used as a diagnostic aid for earlier detection of cervical cancer in young women with gynaecological symptoms by ruling in urgent referral.

/pdf/cytology-in-the-diagnosis-of-cervical-cancer-in-symptomatic-4i19vyrloi.pdf

Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review

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Papers

Evaluating cytology for the detection of invasive cervical cancer

Cervical cytology and the diagnosis of cervical cancer in older women

Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review