'Rapid-Onset' Cervical Cancer Due to Failures in a Screening Program
'Rapid-Onset' Cervical Cancer Due to Failures in a Screening Program
ABSTRACT & COMMENTARY
Synopsis: Rapid-onset cancer is rare; most cases represent false-negative cytology.
Source: Roy M, Plante M. J Low Gen Tract Dis 1998; 2:76-79.
The purpose of this article (though it is more of an editorial than a scientific article) was to consider the concept of "rapid-onset cervical cancer." Roy and Plante reviewed the literature on this topic and found that up to 40% of cervical cancers are diagnosed within three years of a negative Pap smear. They cite four studies with a total of 1613 cases in which cervical cancer was diagnosed within a three-year time period after a negative cytologic specimen. A modification of their data is shown in the Table. They use these data to suggest that rapid-onset cancer is relatively rare.
Table
Pap Smear Screening-"Rapid Onset" CA
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| Cases |
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| Neg Cytology |
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| Neg after review |
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Roy and Plante then discuss the various methods by which cytologic screening might be improved. Five different approaches are mentioned:
· Shortened screening interval
· Screening colposcopy
· Screening cervicography
· Routine HPV-DNA testing
· Improved cytology QA
Roy and Plante reject all except the last of these as being efficient methods of reducing the false-negative rate of Pap smears. Shortening the screening interval dramatically increase costs for little additional return. Colposcopy has far too many false-positives, as does cervicography. HPV-DNA testing is no better or worse than cytology screening but can be considerably more expensive. Thus, they argue that improving the quality assessment of cytology (both the laboratory portion and the clinician portion) is the most cost-effective way to decrease false-negative smears.
COMMENT BY KENNETH NOLLER, MD
For several years, I have been worrying about the possibility that there is no such thing as rapidly progressive or rapid-onset cervical cancer. Many cases in which the diagnosis is made at an advanced stage where there is a history of negative Pap smears have now been the subject of malpractice litigation, and, many times, review of the old negative slides has found clear-cut evidence of malignant cells-often for several years prior to the diagnosis. The so-called small cell cancer of the cervix is one that is frequently said to be rapidly progressive. However, review of old material from some of those cases has now found clear evidence of malignancy for years. Small cell cervical cancer may be no more aggressive than ordinary squamous cell carcinoma.
I was somewhat surprised that Roy and Plante did not mention the possibility that some of the new computerized methods of Pap smear review might also reduce the false-negative rate of Pap smears. While these new techniques are only marginally better than conventional cytology review, the place where they may show the greatest benefit is in their ability to identify small cell cancers of the cervix-a difficult diagnosis for a cytotechnologist since, often, there are few malignant cells on the slide. However, because cervical cancer is now such a rare disease, the added cost of these computerized procedures may be too great for population screening. We will need to await further evaluation of their cost-effectiveness before using them for all cervical cytology samples.
This is another thoughtful article that is found in a relatively new publication, Journal of Lower Genital Tract Disease. This journal is published by the American Society for Colposcopy and Cervical Pathology and, for the past two years, has been presenting original articles as well as reviews and editorials of high quality. I highly recommend it if you are interested in lower genital tract diseases.
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