M™ m CERVICAL CANCER ! interval of yes. By contrast, the 2004 International Agency For Research om Cancer (ARC) recommendations specify that women aged 25-49 yeues undergo screening every 3 years sand those aged! 50-64 years undengo serecning every 5 These recommendations were adopted by the UK in 2003) A comparative approach between Australia and the UK in ems of screening policies, participation eates, and outcomes ‘ul respect to cancer incidence can lead to valuable insights {Examination of the crude participation rate in Austal demonsirtes a 2-year participation rate of 61% and a Sear participation rate of 7496 The UK year participation rte ‘as 66% and the 5-year panicipation rae was 83%. Daua from the NSW Pap Test Register show exo peaks in re-sersening rates, the fist occuring at 1 year, and the other between 2 and 25 years, These data Wlusirte that annual screening con- linues he a rektvely common practice in Ausra, In con lsast, data from Oxfordshire show thar the peal re-sereening timing in Ue UK, prior 10 the implementation Of the 2003 changes, was between 3 and 4 year. Sasieni ef af 2003' has demonstrated a discontinuous relation: ship berween time since # newtive smear and sk of cereal cancer. In women below 50 years of age in the UK, the pre leetive effect of a negative screen remains in place lor approximately 3 years and then rapidly nets to levels close to baseline. In women aged oxer 3, the protect effect per- sists for approximately 5 years In somen aged 50-61 years, the rate of conical cancer in the [UK fn the years 1988-2000 ws lower than that in the com parableage group in Australia, even with the pre-2008 UK. policy of mixed 3-5 year screening intervals. This probably reflects the Jonger duration of protective effect of 2 negative aye wroup. In the over 65 age group, the rate oF cersial cancer In the UK overtakes that sn Austral, prob a screen in this ¥ asa result ofthe UK sercening program langeling wouren under 65, while in Austalia, women up to the age of 70 com liawe to be included in screening program, Among Austrian women under the age of 50 years, the rates ‘of cvavieal cancer are substanilly lower than im he UK. This ‘may in part he at reflection of differences in mangement Another contributing Eictor may be the semening interval Peak se-sereening in the UK occurs after $4 yeurs which may be longer than ideal given the shorter persistence af a p= lective effet in this age group, “To summarise the implications for Australian screening poli ‘ey, the international data suguest that screening in women aged under 25 years should be reviewed, In women aged 25-49 years, Australia could potentially afford co shift the re screening peak from the current 1-5 years to 2-3 years, ‘whilst in women aged 50-64, the screening intereal could potentially be eatended, The current strategy of screening until age 7) appears to be eflevtive, However, moze reseuch is needed wo examine the duration of proeetive effect of negative sercening test under Australian conditions, to essess ARTICLE the impaet of revent management changes upon these eon sions, and 16 infortn potiy- makers Reference 1. Sasieni P, Adams J, Cusick J. Benelt of cervical sereening at Sfferent ages: cvience from the UK audit of sereening, histories. BF Camcor 2008; 89: 88-93. TruScreen - The Australian experience Dr David Itzkowic Gynaocologist, Bondl Junction, NSW Deborah Cromer BSC Statatal analyais| ‘The Pap smear bas significant shostcontings in terms of its sensitivity, bur continues to perform as a very specific test. It misses a significant umber of abnormalities, with data sus esting that up to 30% of cervical cancer patients may have received a normal smear result on cytology screening, ‘Truscreen is used in conjunction with a conventional ‘erological Pap teas te improve accuses. Truscrcen handpiece with opyiel sensors that emit number of discrete wavelengths in the visible and infrared regions of the spectrin as well ceical dive, Up 0 24 sites are sumpled daring the {examination. The device then analyses hackscatered. light dlizect reflectance aad electrical response curves of the issue ss an electrical biosensor to stimulate find these ate demographically matched tissue available instantly. Trusercen is listed oa the Australian Register of Therapeutic Goods and is compared with an existing database of signatures.” Results are marked in Europe as fam aljunet 0 conventional Pap testing. Recently. ic has also been apprened in pars of Asia De Tekowic presented an analysis of 456 patients sereened in huis practice heeween May 2008 and December 2004, None of the som Trusereen, 4 Pap screen, and if Trascreen results Were abnor real, inuoediate colposcopy was perloemed, Patients sith an abnormal Pap smear were also recalled for colpascopy sn offers! the (est refused. Patients underwent OF the entire sample, 8 patients (19.38 bad abnormal Lruscaeen sestlts. On colposcopy 47 (1V.$6) had abnormal results, aad 41 (8990) had normal zesults, OF the 13 women wu CIN Testons, seven Were icleniied only by Truscreen and wo were identified only by Pap smear, Both tests iden biffed am additional ewo CTX lesions, ane the final re of the 13 CIN lesions were missed by bath metlexs, Overall, she Pap smear identied only four of the 13 (30.700) CLN patients, while combined Pap smear and Truscren detected (8.096) cases Gee Figure 1, page 1D. De ltakowsie explained that parients felt reassured by: the available through combined use of ind) conventional Pup testing. "The immediate Increased accuracy “Trusereen 1314 ARTICLE availablity of results provided by Truscreen was an adh tional advantage and allogvod further investigations (eg, vl [potcopy) to he periormed at the same time. He concluded that as an adjunet to Pap testing, Trusereen is a significant improvement in the detection of CIN lesions compared 10 use of the Pap smear alone, Patients ace very necepting of the combined! Truscreen al Pap testing appeeweh, More investigation is required to accurately define the potential of the Tw Figure 1 Cervical histology - The gold standard? Huw Lewellya Staff Pathologist, ACT Pathology, The Canberra Hospital, ACT ‘adigonal diagnostic entera for the evaluation of cervical cytology have heen in place for approximately Significant part of the problem with existing Gehe classification of abnormal cytology lies int multiple processes being under way at diferent cervical sites, Including replication, —pre-neoplastic transformavon, immature neoplasia and rewctve changes 50 years A e presence of produense vital Moxphotogical diagnosis tends to be subjective, an ane al evidence suggests that the natural desire to avoid missing high-grade squamous intrsepiilil lesions (JISIL) may result in “overcalling”, This approsich does no accommodate the range of reactive changes that may be present, andl immanire metaplasia may confound classification In low-grade sqnamous intraepithelial lesions (ISIL), HPV changes are only observed in the upper endothelium nd HPV DNA is only expressed in this upper endothelium, la IL, the HPV genome is integrated into the basal epithelium sem cell genome, and unconulled epithelial proiteration ccecurs with the nuclear abnormalities present in basal Stem cells persisting upward through the cervieal epithelial cells Studies of the diagnostic framework for cervical cancer po posed by De Christopher Krum of the Brigham and Women's Hospital in Woston’ demonstrate a higher level of inte anc | CERVICAL CANCER = mm interobserver reprodueibiliy of results. compared w “observers using the Bethesela system, Molecular stlcs also support the use of Dr Crum’ system. Fisology remains the gol! standart forthe evaluation of eer vical cytology. and will remain s0 for the foreseeable future However, tacitional diagnostic erteria are suboptimal. The Uliagnoste entesia developed by Dr Christopher Crum warrant archer consi ction as their use improves the elaractersa- tion af tae igh grade disease as high risk IIPV types prefer Lentially segreate fat the HSHL category. Dr Gnura lis p> lished « comprehensive monograph sllastating his oak and hie continues 0 refine his elasiication system, Reference 2. Crum CB, Cibas HS, Lee KR, Pathology of Karly Cervical Neoplasia, Churchill Livingstone, 1996, Session 2 HPV Testing - Where are we? Professor Henry Kitchener Proteseor of Gynaecelogical Oncology, St May's Hospi, Manchester UK Prifessor Henry Kitchener commented on the potential place of MPY testing in the analysis of cevvieal cytology. He discussed the ongoing ARTISTE (A Randomised! ria of HPV Testing in Primary Cervical Sensening) tl which is invest- dgiting the use oF NPY testing ast primary screening (00) ARTISTIC involves 25,000 women aged 20-64 years attending jaeneral pricties for tune cervical screening znd whe. con= sent «0 having an HPV est. began in June 2008 with fall resis expected in 2007-8, The study has been designed «0 provide clear evidence on the costs, medical effets and psy chosocial impact of combining MPV testing with cervical cytology. 11 ill also evaluate the effectiveness of standalone PY resting, and sts impact on sensitivity, specie ane he re of inaclequate sees Aller providing consent, subjects were randomised! 3:1) having the HPV result either revealed or concealed c beth women and investigators. Women in the revealed nm who ave HIPV postive with a nggaive smear will undergo repeat resting at 12 months, and colposcopy willbe offered 10 those wha are stil HPV postive All participating women will be re-screened after 3 years 10 determine whether, as a result of HPY testing, there is a redhuced incidence of pre-eaneers a this time point, Another iamportane objective i 10 determine the psychological impact lof HPY testing, given that i s sexually trinsmited and may foause women to Teel anxious o* embarrased. The thie key outcome is 10 determine whether HPV testing is cost effective, ie, whither the addtional cost of the tess satisfied by high- ce detection rates or bus the potential to save costs elsewhere in the programne, ‘he final resus will be published in 2087.