Screening for Cervical Cancer Precursors to Prevent Invasive Disease

In many developed countries a decline in the incidence and mortality of cervical cancer has been observed in the past 30 years. The description of a cytological technique of cervical cancer detection by Papanicolaou in 1941 has given rise to the most successful early detection scheme worldwide. Population-based screening programs or opportunistic screening systems have been implemented in many affluent countries for decades. Due to lack of resources and infrastructure, however, these programs have not been implemented easily in other, less developed parts of the world. The problems encountered in screening for cervical cancer precursors with the aim to prevent invasive carcinoma depend on many different social and political issues, such as lack of patient knowledge, unwillingness of patients to participate in a screening program, or program quality. These issues should be addressed accordingly.

In early cancer detection, different cytological classification schemes, and depending on these, different disease management systems, are used. These different ways of diagnosing and treating diseases are not to be considered as "wrong" or "false," they depend on country-specific conditions. The value of a classification and management system of a disease should be measured on a list of things: if it is meeting the (rightful) expectancies of the patients and their physicians, if it is scientifically correct, and if it can be practiced in line with the medico-legal and medico-economical environment.

In the USA the cytological classification most commonly used is the Bethesda system (Solomon and Nayar 2004), originally developed in and for the USA. Many European countries use different classifications, based on the original Papanicolaou system, of which the Munich nomenclature is the most widely accepted. According to the cytolog-ical classifications, the therapeutic consequences vary: for instance, in the USA, cervical intraepithelial neoplasia (CIN 2 and CIN 3 (HSIL) lesions) are removed by surgery, whereas in Europe, especially in Germany and the Netherlands, only CIN 3 lesions are seen as the direct precursor of invasive disease and therefore surgically removed.

New screening and diagnostic techniques that will lead to changes in already existing programs should be implemented only if the existing problems have been addressed and if the new techniques are evaluated with state-of-the-art methods.

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