Bulletin of the Pan American Health Organization最新文献

The work reported here, which was performed in Santiago, Chile, in 1993, explored factors relating to low Pap test coverage. A survey instrument was prepared and interviews were obtained with 299 women 25-54 years of age who were attending three primary health care clinics in Santiago. Most (at least 87%) of these women had not had a Pap test in three years. Only 28% knew the test's purpose was to detect cervical neoplasia; most (58%) knew the test was related to reproductive health but did not have a clear idea of its purpose; 14% knew nothing of the test or gave completely incorrect answers. Health personnel and the mass media were cited as principal sources of information about the test. Regarding anxieties relating to the test, 60% of the women said they were afraid of being reproached by a health practitioner for failing to come in sooner; 39% said they feared pain resulting from the test; 20% said they feared bleeding; and 14% were afraid they might lose part of the uterus. Also, of the 231 women with intrauterine devices, over 25% said they feared removal of the device. These results suggest a need to improve communication between health care workers and their patients, and to ensure that health personnel respect the rights of women, especially their right to sufficient information enabling them to make their own decisions.

Many developing countries face serious obstacles that have hindered establishment of successful cervical cancer control programs. Various countries are now seeking to strengthen cytology services and identify simple low-cost screening strategies; but any real gains in reducing cervical cancer incidence and mortality will also require effective treatment of women with preinvasive disease. Despite a trend toward conservative outpatient approaches for treating cervical dysplasia in industrialized countries, clinicians in many developing countries still rely primarily on invasive inpatient methods such as cone biopsy and hysterectomy. For women who could be treated with less invasive methods, these procedures tend to pose unnecessary risks and entail high costs that put them beyond the reach of many patients. Outpatient therapy, employing methods such as cryotherapy and the loop electrosurgical excision procedure (LEEP), combined with proper follow-up, is appropriate for dealing with visible lesions on the ectocervix when invasive cancer and endocervical involvement have been ruled out. Cryotherapy and LEEP hold out particular promise for developing countries because of their effectiveness, lack of side-effects, simplicity, and low cost. Cure rates range from 80% to 95%, depending on the method used and the severity of the lesions. However, each method has advantages and disadvantages that demand consideration. Various ways of reducing the number of follow-up visits, including the two-visit "see and treat" approach, are also available for use in areas where women's access to health services may be limited. A recent survey by the Program for Appropriate Technology in Health (PATH) affirmed the tendency to rely on cone biopsy and hysterectomy. It also found that in many places all degrees of preinvasive disease were treated, rather than only high-grade or severe conditions; that respondents in Latin America, the Caribbean, and Asia tended to use cryotherapy and LEEP more widely than other low-cost methods; that LEEP was preferred over cryotherapy in Latin America; and that colposcopes and other basic equipment needed to provide treatment were not consistently or widely available in some settings.

To assess the reproducibility of diagnostic results obtained by examining Pap smears for cervical neoplasia, a study was conducted using a single group of 20 Pap smears, 3 negative and 17 from patients with varying degrees of neoplasia. These smears were examined by 14 volunteer readers (13 cytotechnologists and 1 cytopathologist) from the Mexican states of Oaxaca and Veracruz, and also by a highly experienced cytopathologist certified by the Mexican Board of Pathological Anatomy whose work provided a reference standard. Individual variability, as assessed by the Kappa coefficient of concordance, showed considerable difference in the diagnostic results obtained by different readers-the degree of agreement depending on the type of cervical lesion involved and the number of specimens from patients with that type of lesion. There was little diagnostic agreement when the specimens were assessed for particular classes of cervical neoplasia-mild, moderate, or severe neoplasia, carcinoma in situ, or invasive cervical cancer. (The greatest concordance was found in diagnosing specimens from subjects with invasive cervical cancer.) However, when the diagnosis was assessed continuously, using Kappa weighted in accordance with the five possible diagnoses of cervical neoplasia, the apparent reproducibility of the diagnoses improved greatly, Kappa coefficients for the 14 readers ranging from 0.31 to 0.72. In general, these data support the view that there is a need in Mexico and other parts of the Americas to establish quality control mechanisms monitoring cytologic diagnosis of cervical neoplasia, to standardize diagnostic nomenclature using a system such as the Bethesda System, to institute periodic certification, and to provide continuing training. As this suggests, it is necessary not only to evaluate but also to bring about organizational changes in order to expeditiously prevent or correct the problems that currently constrain achievement of efficient and effective cytologic diagnosis.

This article presents an assessment of cervical cancer mortality trends in the Americas based on PAHO data. Trends were estimated for countries where data were available for at least 10 consecutive years, the number of cervical cancer deaths was considerable, and at least 75% of the deaths from all causes were registered. In contrast to Canada and the United States, whose general populations had been screened for many years and where cervical cancer mortality has declined steadily (to about 1.4 and 1.7 deaths per 100,000 women, respectively, as of 1990), most Latin American and Caribbean countries with available data have experienced fairly constant levels of cervical cancer mortality (typically in the range of 5-6 deaths per 100,000 women). In addition, several other countries (Chile, Costa Rica, and Mexico) have exhibited higher cervical cancer mortality as well as a number of noteworthy changes in this mortality over time. Overall, while actual declining trends could be masked by special circumstances in some countries, cervical cancer mortality has not declined in Latin America as it has in developed countries. Correlations between declining mortality and the intensity of screening in developed countries suggest that a lack of screening or screening program shortcomings in Latin America could account for this. Among other things, where large-scale cervical cancer screening efforts have been instituted in Latin America and Caribbean, these efforts have generally been linked to family planning and prenatal care programs serving women who are typically under 30; while the real need is for screening of older women who are at substantially higher risk.