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a Groote Schuur Hospital, University of Cape Town, H45 Old Main Building, Observatory 7925, Cape Town, South Africa
University Department of Obstetrics and Gynaecology and Oncology/Dysplasia Unit, Royal Womens Hospital, Melbourne, Australia
c Screening Group, International Agency for Research on Cancer, Lyon, France
Abstract
Organised and quality assured cytology-based screening programmes have substantially reduced cervical cancer incidence in many developed countries. However, there are considerable barriers to setting up cytology-based screening programs, particularly in developing countries.
This has stimulated the search for novel and alternative approaches to cytology for cervical cancer prevention. These approaches generally
perform as well as cytology, and sometimes better, although many of them have a lower specificity, resulting in higher false-positive rates. The
possibility of linking screening to treatment in a one- or two-visit strategy appears to be safe, feasible and effective. Barriers to establishing
screening programs and the pitfalls encountered differ from one country to the next. Country-specific solutions need to be found, while being
cognisant of the criteria that have enabled successful screening programmes.
2006 Elsevier Ltd. All rights reserved.
Keywords: Cervical cancer; Screening; Developing countries
1. Introduction
Successfully organised, population-based cervical cancer
screening programmes have not yet been implemented in
most developing countries, despite the greatest burden of cervical cancer in these countries [1], which is largely related to
poverty, lack of resources and infrastructure and disenfranchisement of women.
0264-410X/$ see front matter 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.vaccine.2006.05.121
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The challenges and failure of cytology screening programmes to be developed and sustained in low-resource
countries has stimulated the search for alternative methods of
screening that would overcome the many barriers identified.
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Table 1
Performance and characteristics of different screening methods
Screening test
Sensitivity
Specificity
Characteristics
Moderate (4478%)
High (9196%)
HPV-DNA testinga
High (66100%)
Moderate (6196%)
Moderate (6779%)
Moderate (6273%)
Moderate to high (7898%)
Low (4986%)
Low (8687%)
Low (7393%)
Colposcopy
Polar Probe
Low (4477%)
Moderate (6774%)
Low (8590%)
Low (6572%)
Conventional
cytologya
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Acknowledgements
7. An experience in South Africa: the Project Screen
Soweto (PSS)
Project Screen Soweto [23] illustrates well the difficulties
of establishing a cytology-based screening programme. In
1980, at Baragwanath Hospital, which is a large tertiary institution serving the inhabitants of Soweto (an African township
outside Johannesburg, South Africa), an approximate 50%
increase in admissions for cervical cancer was documented,
from 150 cases in 1970 to 236 cases in 1980. In addition, an
excess of 70% of women with abnormal cervical smears had
not been followed up. In recognition of the poor quality of the
existing opportunistic screening programme and the apparently rising incidence of cervical cancer, PSS was initiated
in 1986 [23]. Prior to the establishment of the project, laboratory capacity for screening had been 3000 and increased to
90,000 smears per annum. Pilot studies identified the prime
screening target as an existing pool of women ages through
the network of primary healthcare clinics. The unresolved
problem at the time was the development of an accessible
public education programme. This problem arose because of
the lack of resources but also due to fears that too vigorous and too early a public education program would flood
an untested screening network and swamp primary healthcare clinics, laboratories, colposcopy clinics and hospital
wards. A decision was thus made to launch Project Screen
Soweto prior to instituting any public health educational
programme.
During the planning phase of the project in 1982, 32,365
smears were taken. After the launch of the project, however,
the number of smears taken decreased to 24,251 in 1983 and
26,216 in 1984. In addition, there was a rapid decline in the
diagnosis of both invasive and pre-invasive cervical cancer,
the opposite of what should occur in a screening program in
a previously unscreened population. The failure of the PSS
was acknowledged 5 years after the commencement of the
project. The reasons for the failure of PSS are complex. An
important cause of the failure of the programme appeared to
be the very low priority given for Pap smears at the level of the
primary healthcare services and the competing health needs
of the largely poor community. In addition, the failure to
establish an effective public health educational programme
resulted in women remaining ignorant about cervical cancer prevention and no consumer demand for screening was
created.
It was calculated, however, that had available laboratory
facilities been utilised to full capacity during that 5-year
period, an excess of 300,000 women in Soweto would have
received at least one smear, which should have detected 6000
pre-invasive or invasive cancers.
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