What constitutes an adequate cervical smear?

Article Abstract:

Although screening tests to diagnose abnormalities in cells of the uterine cervix (Pap tests) and, most importantly, cervical cancer, have been in use for 30 years, researchers still disagree about the optimal type of cervical specimen required for accurate diagnosis. Cervical smears consist of cells removed from the cervix for histological analysis, and it is considered important to include endocervical cells (from within the cervical canal, rather than at its margin) in the smear. This may be difficult in postmenopausal women, since their anatomy has altered in such a way that the junction between endocervical cells and the cells that cover the external cervix has moved farther up into the canal (making endocervical cells less accessible). When negative smears (those lacking suspicious cells) were compared with positive smears from the same woman, the negative smears were less likely to contain endocervical cells; however, results of a study that reported this observation were not statistically significant. Another study found a higher rate of abnormal cell change in smears with endocervical cells than in smears that lacked them on a second screening of a large number of women. Different spatulas for sampling cervical cells have been designed; two are compared in an article in the January 1991 issue of the British Journal of Obstetrics and Gynaecology. Ideally, a good smear contains significant numbers of cells obtained by a circular sweep over the whole cervical surface. This is as much a matter of training in good smear-taking technique as it is a function of the spatula used. Many clinicians are not appropriately trained to take adequate smears, and only acquire skill from practice and via negative feedback from pathology departments who request repeat smears. Nurses may not persevere in asking a physician for help if the cervix is difficult to find, and may sample from the vaginal wall instead. Nor are they trained to recognize pathological changes in the cervix. Anyone who takes smears needs formal training in the best sampling methods. Screening tests for cervical cancer should offer women an improved chance of early diagnosis and cure; false negative reports are only a hindrance in this regard. (Consumer Summary produced by Reliance Medical Information, Inc.)

Identification and classification, Cancer cells

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The treatment of CIN: do we need lasers?

Article Abstract:

Modern approaches to treating cervical intraepithelial neoplasia (CIN, abnormal cervical cell changes that, in extreme grades, are diagnosed as cancer) increasingly emphasize conservative approaches. Hysterectomy (removal of the uterus) has been largely replaced by cone biopsy (removal of a cylinder of diseased tissue surrounding the cervical canal) or by local destruction of the tissue. Colposcopy (examination of the cervix and vagina with a brightly lighted magnifying lens) allows women with CIN to be evaluated individually so that the most appropriate treatment is applied to the affected tissue. Local destruction can be accomplished by diathermy (heat), cryosurgery (freezing), cold coagulation (using, in spite of its name, temperatures as high as 120 degrees Centigrade), or carbon dioxide laser treatment. Each method has its advocates among clinicians, but diathermy and cryosurgery are less favored because the former requires a general anesthetic and the latter is not consistently successful. Laser treatment is more expensive and no more effective than cold coagulation; the latter should become the treatment of choice in the UK. Some researchers believe that excision is a more reliable treatment for advanced CIN (such as CIN 3, a stage in which atypical cells have invaded much of the cervical tissue), compared with destruction; a cone biopsy is the traditional method. Greater areas of diseased tissue are less effectively removed with the laser, as precise control of the depth of destruction is difficult. Large loop excision of the transformation zone (LLETZ; use of diathermy loops to remove affected tissue) is a new technique which has the drawback of altering tissue histology by its heat. Long-term studies are needed to evaluate different methods of treating CIN, and they should consider potential effects on fertility and pregnancy. Results indicate that lasers are no more effective than cold coagulation (and, perhaps, other approaches); this fact, plus their high cost, fails to justify their use in treating CIN. (Consumer Summary produced by Reliance Medical Information, Inc.)

Surgery, Cervix uteri biopsy

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Criteria for standards of management of women with an abnormal smear

Article Abstract:

Objectives are presented for a screening program for cervical cancer based on results from the Pap smear. Colposcopy (use of a bright light and magnifying lens to examine the vagina and cervix) should be performed for patients thought to be at increased risk for cervical cancer, based on cytology or results from examination. In England and Wales, the annual incidence of cervical cancer is 18.9 per 100,000 women older than 14; among women aged 60 to 64, it is 30.9 per 100,000. Cervical cancer rates for women with different stages of cervical intraepithelial neoplasia (CIN), a precancerous condition, are discussed. Colposcopy is subjective and a difficult technology for which quality control guidelines are hard to formulate. In addition, punch biopsies (removal of small pieces of tissue with a punch) can be unreliable and histopathology can be subject to varying interpretations. The effectiveness of treatment should not be evaluated until six months have elapsed, since healing can produce artifacts that resemble CIN. Follow-up should identify residual or recurrent disease to determine whether treatment caused any complications. Treatment failure is usually apparent within the first year and occurs in approximately 5 percent of cases; failures are seen at a rate of about 1 percent each year thereafter. Physicians need to be attentive to the patient's fear of cancer and other fears, such as those related to the procedure. Patients can convey their concerns by completing an anonymous questionnaire, which may allow them to be more candid. Waiting time for first appointments or treatments should not exceed three months (the authors practice in Great Britain). (Consumer Summary produced by Reliance Medical Information, Inc.)

Editorial, Medical examination, Vagina

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