List of participants . . . . . . . . . . . . . . . . . . . . . . . . . ix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi 1. Cervical cancer and screening . . . . . . . . . . . . . 1 Cervical cancer incidence and mortality worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Pathology of cervical neoplasia . . . . . . . . . . . . . . 9 Diagnosis and treatment of cervical preinvasive and invasive disease . . . . . . . . . . . . . . . . . . . . . 18 The etiology of cervical cancer . . . . . . . . . . . . . 26 Principles of screening . . . . . . . . . . . . . . . . . . . 45 Natural history of cervical cancer . . . . . . . . . . . . 46 Considerations for screening programmes . . . . . 57 2. Screening tests . . . . . . . . . . . . . . . . . . . . . . . . 59 Cervical cytology . . . . . . . . . . . . . . . . . . . . . . . . 59 Visual inspection . . . . . . . . . . . . . . . . . . . . . . . . 76 Colposcopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Cervicography . . . . . . . . . . . . . . . . . . . . . . . . . . 90 . HPV DNA testing . . . . . . . . . . . . . . . . . . . . . . . . 93 Combinations of different modalities . . . . . . . . . 109 3. Use of screening for cervical cancer . . . . . . 117 Delivery and uptake of screening . . . . . . . . . . . 117 Behavioural considerations in screening . . . . . 147 4. Efficacy of screening . . . . . . . . . . . . . . . . . . . 163 Methodology and analytical issues in assessment of efficacy . . . . . . . . . . . . . . . . . . 163 Cytological screening . . . . . . . . . . . . . . . . . . . 168 Visual inspection . . . . . . . . . . . . . . . . . . . . . . . 183 Human papillomavirus testing . . . . . . . . . . . . . 186 Other screening methods . . . . . . . . . . . . . . . . .191 Efficacy of screening among HIV-positive women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 5. Effectiveness of screening in populations . . 201 Incidence and mortality trends in relation to screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201 Issues in the implementation of screening . . . . 212 Hazards of screening programmes . . . . . . . . . 214 Performance evaluation . . . . . . . . . . . . . . . . . . 217 Economic evaluation and cost-effectiveness of cervical cancer screening . . . . . . . . . . . . . . . . 223 6. Summary of data . . . . . . . . . . . . . . . . . . . . . . 227 7. Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 8. Recommendations for public health implementation and further research . . . . . 239 . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Working procedures . . . . . . . . . . . . . . . . . . . . . . 299
Cervical cancer is still one of the most common forms of cancer among women, despite the success of screening for precursors of the disease using the widespread cytological procedure, the Papanicolaou (or Pap) test. This volume reviews what is know about the occurrence, natural history and causes of cervical cancer, before describing the established methods and newer variants and approaches for screening that are now being introduced, tested or investigated. Based on an international meeting of experts, the volume concludes with their evaluation of the evidence on the efficacy of screening, in.