[Indicators and standards for evaluating the program process for cervical cancer screening. Operation manual. Italian Group for Cervical Carcinoma Screening].
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Colposcopy↗
Biomedical subjects
A Iossa
Publications and source records attributed to A Iossa.
Upper age limit for cervical cancer screening.
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Age Factors↗
Trends in cervical cancer incidence in the district of Florence.
The trend in cervical cancer incidence in the District of Florence from 1975 to 1989 was investigated. Tuscany Cancer Registry data were available since 1985. Incidence data from 1975 to 1985 were obtained through a retrospective survey of all the Departments of Pathology and Gynaecology in the district. Cytological screening for cervical cancer has been available in the district since 1973, and since 1980 active invitation of residents aged 25 to 59 years has been in use. A significant trend in decreasing incidence was evident for the overall population (P = 0.003) and for 40-49 (P = 0.028), 50-59 (P < 0.001) and 60-69 (P = 0.002) year age groups, whereas no significant trend was observed for the age group 30-39 years. An association between attendance to screening and reduced incidence was evident, in that a greater reduction was evident for those cohorts (ages 50-59 and 60-69) who had a higher compliance to screening 10-15 years before. If the decrease in cervical cancer incidence was spontaneous, a parallel decrease of CIN3, which is commonly assumed to be the precursor of invasive carcinoma, would be expected. On the contrary, the detection rate of CIN3 at first Pap test showed a significant increase in the study period. All these findings suggest that the observed reduction in cervical cancer incidence was mostly due to the effect of screening, and stress the need for optimising the coverage of the invited population.
Adult↗
Screening history of incident cases of invasive carcinoma of the cervix. Florence district 1988-1989.
BACKGROUND: Incidence cases of carcinoma of the cervix may be assumed as failures of a population-based cytologic screening program. Monitoring such cases would provide an estimate of screening effectiveness, and evaluating the causes of the failures would improve screening performance. STUDY DESIGN: All incident cases of cervicocarcinoma registered in 1988 and 1989 in the Tuscany Tumor Registry were eligible for the study and were reviewed. RESULTS: Sixty-nine eligible cases were considered. Non- or irregular attendance (negative smear-to-diagnosis interval > 5 years) for the Pap smear was recorded in 53 subjects. A false-negative smear (smear-to-diagnosis interval < 5 years) and refused or inadequate assessment/treatment at private practices or local hospitals were recorded in 12 cases. False-negative smears by the local screening program were recorded in 4 cases only. CONCLUSIONS: Non- or irregular attendance was the major cause of screening failures. Since cytologic screening or diagnostic assessment outside the screening program may be inadequate, central screening and follow-up is recommended. Non-attenders showed a strong negative attitude towards screening, and general practitioners and gynecologists need to be further stimulated for systematic screening promotion. Immediate evaluation of the screening history of incident cases of cervicocarcinoma should be mandatory in any screening program.
Adult↗
Testing cervicography and cervicoscopy as screening tests for cervical cancer.
AIMS AND BACKGROUND: Suboptimal sensitivity is currently reported for Pap test in screening for cervical cancer. Colposcopy is known to be more sensitive than cytology but its use as a screening test is not possible due to costs and complexity. Screening by cervicography has been suggested as a compromise being less costly and feasible. The present study evaluates the feasibility of screening by cervicography and cervicoscopy (naked eye examination of the cervix after acetic acid lavage) on a consecutive screening series. METHODS: Cervicography and cervicoscopy were performed by the smear taker in subjects consecutively attending a screening clinic. Women with abnormal cytology (atypia or more severe lesion) and/or abnormal cervicography or cervicoscopy (acetowhite lesion) underwent colposcopic assessment. The three screening methods were compared according to positivity rate, CIN 2-3 detection rate and positive predictive value. RESULTS: 2105 consecutive subjects were screened. Positivity rate was 3.8%, 15.3% or 25.4% for cytology, cervicography or cervicoscopy, respectively, 486 of 555 women attended the assessment phase, 281 directed biopsies were performed and 8 CIN 2-3 lesions were detected. Cytology, cervicography and cervicoscopy, detected 5.5, or 7 of 8 CIN 2-3 lesions, respectively. The positive predictive value was 0% for cytologic atypia, 25% for cytologic SIL, 1.75% for cervicography and 2.05% for cervicoscopy. Detecting one CIN 2-3 lesion at cytology cost $5,543. The cost per each additional cytologically negative CIN 2-3 lesion detected at cervicography or cervicoscopy was $12,947 or $3,916, respectively. CONCLUSIONS: The study confirms the limited sensitivity of cytology for CIN 2-3. The association of cervicography was not cost effective. Cervicoscopy was poorly specific but increased the detection rate of CIN 2-3 at relatively low costs. Cervicoscopy is worth further evaluation as a screening test.
Adolescent↗
Quality control for colposcopy in the Florence screening program for cervical cancer.
The authors report on the quality control for colposcopy adopted in the Florence District screening program. The sensitivity of colposcopy was determined on all cases of CIN III recorded in the local cancer registry in a four-year period. However although this showed that a centralized colposcopic clinic employing a limited number of expert operators is superior to the performance of colposcopy in private practice, such a parameter was impractical for further routine quality control since differences among operators were too small and statistically insignificant. Other parameters for quality control were chosen, namely a) the rate of colposcopically directed biopsies performed, b) the detection rate of CIN II or more severe lesions, and c) the positive predictive value of a directed biopsy for CIN II or more severe lesions. Analysis of these indicators after stratification by cytologic report allows the identification of those operators who need additional training and provides useful information for colposcopists to optimize their diagnostic and operative criteria.
Adult↗
Evaluation of the sensitivity of cervicography in a consecutive colposcopic series.
Cervicography was performed in 606 women referred for colposcopy. Cervigrams were blindly reviewed by two independent readers. The positivity rate at cervicography was high (operator A = 50%, B = 58.8%). The sensitivity for papillomavirus infection (HPV)/cervical intraepithelial neoplasia I (CIN I) (n = 141) was 79.4% for operator A and 80.8% for operator B. The sensitivity for CIN II or more severe lesions (n = 22) was 95.2% and 90.5% for operators A and B, respectively. The positive predictive value for HPV/CIN I or CIN II, or more severe lesions was 36.9% and 6.9% for operator A and 32.1% and 5.3% for operator B, respectively. Interobserver variability was acceptable (kappa = 0.62). Cervicography suspected 27 HPV/CIN I, 1 CIN II and 1 CIN III which showed no cytologic abnormalities. This study confirms that cervicography has a good sensitivity for cervical lesions, but it is based on a selected series, not representative of a screening condition. The combination of cervicography and cytology in screening is presently under evaluation in a prospective study of screened women.
Adult↗
Hysteroscopy and endometrial cancer diagnosis: a review of 2007 consecutive examinations in self-referred patients.
The authors reviewed 2007 consecutive outpatient hysteroscopies performed in self-referred women to assess the detection rate of uterine cancer and the validity of different selection criteria for hysteroscopy. Thirty cases of uterine cancer (29 endometrial, 1 carcinosarcoma) were detected. Abnormal uterine bleeding was the indication most commonly associated with cancer (26 of 30 cases, cancer detection rate = 2.1%), whereas the presence of cervical polyps had no predictive value. Patients age was correlated to cancer detection rate, and the investigation of uterine cancer under the age of 45 was poorly cost effective. Hysteroscopy and endometrial biopsy, performed by Permacurette or Novak curette immediately after hysteroscopy, missed respectively 8 and 2 of 30 cancers. Hysteroscopy should be employed in combination with endometrial biopsy as a standard outpatient investigation whenever endometrial cancer is suspected. These procedures are safe and accurate and rule out more aggressive and costly procedures, such as dilatation and curettage, in most cases.
Adolescent↗
Response of primary breast cancer to tamoxifen alone in elderly women.
The authors report on a consecutive series of 62 evaluable, elderly (age greater than 69 years) women with primary operable breast cancer treated only with tamoxifen. The treatment schedule was 160 mg on day 1 followed by a daily maintenance dose of 20 mg. Compliance to treatment was excellent, and subjective side effects were minimal. The best response achieved after at least 6 months of treatment was complete in 7, partial in 22 and minor in 3, whereas stable disease or progression was observed in 28 and 2 patients, respectively. The response rate decreased and progressions increased with time. At 6, 12, 24, 36 and 48 months of treatment, the complete + partial response rates were 30.6%, 45%, 45.6%, 38.7% and 25% and the progressive disease rates 4.8%, 19.6%, 34.8%, 45.2% and 66.6%, respectively. These results do not confirm some previous reports of a high response to tamoxifen. This difference is only partially explained by the use of mammography, which is more sensitive than palpation, to assess tumor size and treatment response. The present study does not support primary hormone therapy as a current alternative to surgery, which should be the standard treatment in otherwise healthy elderly patients with operable breast cancer.
Aged↗
Subclinical vulvar papillomavirus infection.
Eighty-eight cases of subclinical human papillomavirus (HPV) vulvar infection were detected in a consecutive colposcopic series of 968 women. Three patterns of acetowhite lesions had a 72% predictive value (88/122) for histologically assessed HPV. The prevalence of subclinical vulvar HPV in self-referred patients was 7.9% (73/918); it was 9% (88/968) in the overall series and significantly higher in younger patients (age less than 25 years: 21/106, or 19.8%) or in those with cervical HPV or cervical intraepithelial neoplasia (CIN) (40/100, or 40%). Routine inspection of the vulva after acetic acid lavage in association with a Papanicolaou test might help identify Papanicolaou-test-negative patients at high risk of developing cervical HPV or CIN. Treatment with beta-interferon (2,000,000 IU daily intramuscularly for 10 days) was given to 30 consecutive patients, but the results were poor: regression was observed in only 2 cases.
Adolescent↗
Male breast carcinoma: review of a multicenter series of 150 cases. Coordinating Center and Writing Committee of FONCAM (National Task Force for Breast Cancer), Italy.
The authors report on a consecutive retrospective series of 150 male breast cancers. Clinical, diagnostic and therapeutic features are compared over time and with respect to a large consecutive series of female breast cancers. Both age at diagnosis and tumor stage were more advanced in males than in females. Poor alertness of both men and doctors for this infrequent disease may account for such a delay in diagnosis. The use of mammography increased over time and sonography or cytology were frequently and successfully employed in the last decade. Unfortunately no improvement of tumor stage at diagnosis was observed over time in the present series. A time trend was also evident for the type of surgical and postoperative treatment. Modified radical mastectomy and adjuvant chemo- or hormone therapy were increasingly adopted, although Halsted operation and postoperative radiotherapy were still common in the last decade due to the relatively high proportion of locally advanced T3-4 cancers. Both disease-free and overall survival were worse in men than in women, even after adjustment by stage at diagnosis. This study suggests that male breast cancer has a worse prognosis with respect to female breast cancer and provides no complete explanation of this finding, except for an intrinsic higher aggressivity. No evidence was found which may justify a different diagnostic or therapeutic approach with respect to female breast cancer.
Adult↗
The role of fine needle aspiration cytology in the differential diagnosis of suspected breast cancer local recurrences.
The authors report on 228 cases of suspected breast cancer local recurrences studied by fine needle aspiration cytology (FNAC). The nature (malignant = 133, benign = 95) of suspected lesions was assessed on histology (no. = 46) or according to unequivocal follow-up (no. = 182). Inadequacy rate was 0.20, 0.09 or 0.35 in total, cancer or benign cases, respectively, and was particularly high (0.50) for benign chest wall lesions. Accuracy was determined on adequate smears; dubious reports were assumed as positive. Sensitivity and specificity were 0.96 and 0.97, respectively. The routine use of FNAC is recommended since it helps in the differential diagnosis of suspicious cases and may bypass surgical biopsy of positive cases not eligible for surgical treatment.
Biopsy, Needle↗
Risk of breast cancer subsequent to proven gross cystic disease.
3809 women in whom breast cysts were aspirated were followed up to evaluate the observed/expected ratio of subsequent breast cancer. Breast cancer at cyst aspiration was excluded by physical examination and mammography. The first year of follow-up was censored to avoid a prevalence screening effect. Subsequent breast cancers were found either directly or by means of a cancer registry which also provided the expected age and residence specific incidence rates. The number of expected cancers was assessed in person-years (15,915 in the total series). The observed/expected subsequent breast cancer ratio was 1.77 (34/19.15; 95% confidence interval 1.23-2.48, P less than 0.05). The presence of gross cysts was associated with a moderately though significantly increased risk of subsequent breast cancer. Increased surveillance in such patients is not justified.
Adolescent↗
Referral policy and positive predictive value of call for surgical biopsy in the Florence Breast Cancer Screening Program.
The authors evaluate the referral rates and the predictive value (PV) of call for diagnostic work up or biopsy in a population based breast cancer screening program in the 1979-1986 period. The presence of mammographic abnormalities either benign or suspicious proved to be the only reliable referral criterion (recall rate = 7.9%, recall PV = 3.8%, biopsy call PV = 39%). When mammography was normal the presence of breast complaints other than pain or of a radiologically dense breast were aspecific referral criteria, and since the latter was abandoned, (a) referral rates dropped especially in younger women, (b) referral or biopsy PV improved, whereas (c) cancer detection rate was almost unaffected. Younger age was associated with higher referral rates and with lower PV of both referral or biopsy. Whenever comparison with previous examination was possible, mammography accuracy was higher; this explains the decrease in referral rates and the increased predictivity observed at further rounds with respect to first screening round.
Adult↗
Colposcopic survey of Papanicolaou test-negative cases with hyperkeratosis or parakeratosis.
A colposcopic survey was performed in 269 consecutive women with negative cytology showing hyperkeratosis or parakeratosis. A colposcopy-guided biopsy specimen of cervical abnormalities was taken in 88 cases, and human papillomavirus infection (HPV) was detected histologically in 25 cases. No cervical intraepithelial neoplasia (CIN) was detected. The detection rate of HPV was not significantly different from that observed in a consecutive series of 1073 Papanicolaou test-negative subjects self-referred for colposcopy. Colposcopic screening of subjects showing hyperkeratosis or parakeratosis with otherwise negative smears is not recommended because it does not allow detection of cytologically false-negative CIN.
Adult↗
In situ ductal carcinoma of the breast--analysis of clinical presentation and outcome in 156 consecutive cases.
We report on 156 consecutive cases of in situ ductal carcinoma (DCIS) of the breast observed from 1968 to 1988. The relative frequency of DCIS was much higher in screened, with respect to self-referred, women and a significant association of DCIS with younger age was observed. The combined use of mammography and physical examination identified 138 of 156 total DCIS cases as suspicious. Mammography, physical examination or cytology (of nipple discharge or needle aspirate) were the only tests to provide suspicious evidence in 35, 22 and four cases respectively. DCIS was a relatively unexpected surgical finding in 13 apparently benign cases. Different surgical options were recorded in the study period but a temporal trend in favour of conservative surgery was evident. Subsequent ipsilateral or contralateral breast cancer was recorded in seven and six cases respectively. Death from breast cancer occurred in five cases, all of whom had contralateral or subsequent ipsilateral infiltrating cancer. This figure confirms the high curability of DCIS if local control is achieved.
Adult↗
Prognosis of nonpalpable infiltrating carcinoma of the breast.
A consecutive series of 185 instances of histologically confirmed nonpalpable infiltrating carcinoma of the breast is presented. Histologic nodal involvement was found in 12 per cent and was dependent on the size of the tumor. Conservative surgical treatment was the predominant method used during the study period. The ten year over-all survival was studied and compared with that of 4,217 instances of palpable carcinoma of the breast observed during the same period. The ten year survival rates were, by far, better for nonpalpable (94 per cent) than for palpable carcinomas (65 per cent). A better prognosis for nonpalpable carcinomas was confirmed also by multivariate analysis (Cox) with adjustment for potential confounders, such as age, stage or nodal involvement. The possible confounding effect of over diagnosis and length or lead time bias is discussed. Although this difference in survival might be partially explained by the aforementioned confounders, the chance of increasing life expectancy and conservative surgical treatment encourages preclinical detection of carcinoma of the breast.
Adult↗
Tumor size and prognosis of breast cancer with negative axillary nodes.
A report on 1877 consecutive node negative (N-) breast cancer cases is presented in which the prognostic value of the main clinico-pathologic features is evaluated. Tumor size (and UICC-TNM T category) and lobular infiltrating histologic type were significantly associated with a more favorable prognosis whereas no association was found for patient age, tumor site and number of examined axillary nodes. However tumor size (and T category) is not a very accurate prognostic predictor (71% of all recurrences observed occurred in cases with tumor diameter of more than 20 mm, which represented 58% of the total series), although its efficiency seems almost as good as that of other more recent prognostic predictors such as estrogen receptor content or labeling index. None of the prognostic predictors currently available, including tumor size, seems sufficiently specific and they do not allow for a reliable selection of high risk N-patients for adjuvant treatment.
Adult↗