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RHO archives : Topics : Cervical Cancer Prevention

Key Issues

This section provides brief summaries of some of the major research areas related to cervical cancer control in low-resource settings. More detailed discussions of specific key issues are included in the Annotated Bibliography.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Epidemiology and natural history of cervical cancer

Cervical cancer develops slowly, and the key precursor is severe dysplasia. Mild dysplasia almost always regresses spontaneously; most moderate dysplasias also regress (Holowaty et al. 1999; Critchlow and Kiviat 1999). Human papillomavirus (HPV) probably is the cause of almost all cervical cancer worldwide (Bosch et al. 1995; Schiffman 1995; Pisani et al. 1997; Hernandez-Avila et al. 1997). A recent study estimates worldwide HPV prevalence in cervical carcinomas at 99.7 percent (Walboomers et al. 1999). Even so, results from the longest longitudinal study of incident HPV infections suggest that, within 36 months of HPV infection, 90 percent of young women had cleared the infection (Moscicki et al. 2001). The risk for developing high-grade cervical lesions appears to be associated, in general, with the persistence of HPV infection and, in particular, with type-specific persistence (Kjaer et al. 2002). Studies also suggest that persistence of HPV infection is related to the development of cancer (Moscicki et al. 2001; Wallin et al. 1999; Burk 1999). Besides HPV, other risk factors appear to include certain sexual activity patterns and smoking (Brinton 1992; Biswas et al. 1997; Prokopczyk et al. 1997, Roteli-Martins et al. 1998; Wen et al. 1999; Kjellberg et al. 2000; Moscicki et al. 2001). Recent evidence from IARC's multi-center, case-control studies suggests that both oral contraceptive use and high parity have a significant association with increased risk for cervical cancer (Muñoz et al. 2002; Moreno et al. 2002). Interpretations of the data are complex, and multiple confounding factors may be playing a role. Certain sexually transmitted infections (STIs) such as Chlamydia trachomatis and herpes simplex virus also may be associated with an increased risk of developing cervical cancer (Anttila et al. 2001; Zenilman 2001; Moscicki et al. 2001; Smith et al. 2002).

In some developing countries, there is concern among clinicians that cervical cancer develops differently from what is traditionally described in Western countries (for example, concern that cervical cancer may develop at younger ages and that dysplasia progresses more quickly to invasive disease) (Rogo et al. 1990). A study of Pap smear results from ob/gyn clinics in South Africa found that a significant proportion of cervical cancer cases occurred in women younger than age 40 (Lancaster et al. 1999). Whether these results would have been the same with a true population-based sample is unclear. In fact, data from a population-based study in Ontario, Canada, showed a pattern of HPV prevalence consistent with a population-based study conducted in Costa Rica. In both studies, prevalence of carcinogenic HPV peaked among women under the age of 25 and had a second peak in women 59 years of age and older (Sellors et al. 2002). Population-based data from two provinces in Thailand show a similar pattern of high-risk HPV infection in younger women, with the prevalence of high-risk HPV peaking in women under the age of 25 and between the ages of 25 and 34 (Sukvirach et al. 2003). Overall, few studies have conclusively demonstrated regional differences in the age-specific risk of cervical cancer; in general, cervical cancer risk peaks about age 50, and severe dysplasia risk peaks about age 35 (Ponten et al. 1995).

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Primary prevention of cervical cancer

Although primary prevention of HPV infection would greatly reduce cervical cancer mortality, the prevention of HPV transmission presents greater challenges than most STIs. HPV generally is asymptomatic and easily transmitted. The virus can exist throughout most of the anogenital area (including areas not covered by male condoms). Although treatment strategies are available for the genital warts sometimes caused by HPV, no therapies exist to eliminate the underlying infection (Koutsky et al. 1999; PATH/Outlook 1998). It is not entirely clear that barrier methods of protection against STIs are effective in protecting women from cervical cancer. A number of studies have found barrier methods to be protective (Grimes et al. 1995; Coker et al. 1992; Thomas et al. 1996), including one study that found condom use significantly reduced the risk of acquiring genital warts (Wen et al. 1999). Other studies have not found a significant association between use of barrier methods and cervical cancer prevention (Hildesheim et al. 1990). HPV DNA also has been detected on the fingertips of persons with genital warts, suggesting a potential for transmission of HPV infection by finger-genital contact (Sonnex et al. 1999), although this may be an unlikely route of transmission (Mindel and Tideman 1999). Researchers also are beginning to focus on the possible role of men who may be acquiring high-risk HPV from frequent contact with sex workers and transmitting the infection to their wives (Thomas et al. 2001). Results from pooled data from IARC's seven case-control studies shows a strong association between circumcision and a reduced risk of penile HPV and subsequent cervical cancer in female partners (Castellsague et al. 2002). Interpretation of the data is complex because of possible confounding factors and the reliability of self-reported circumcision status. Certainly, sexual abstinence or lifetime mutually monogamous relationships would prevent the transmission of HPV; however, these options may not be realistic for many individuals. Other suggestions of primary prevention strategies for cervical cancer are based on risk associations in case-control studies and include avoidance of cigarette smoking and maintaining a high dietary intake of vitamin C (Grimes et al. 1995). Both the World Health Organization (WHO) and the National Institutes of Health (NIH) also recommend sexuality education and efforts to change sexual behavior as part of their primary prevention strategies (WHO 1985; NIH Consensus Statement 1986; Shepherd et al. 1999).

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Screening: assessment of alternative screening approaches

In industrialized countries, cervical cancer incidence and mortality have been reduced significantly through Pap smear screening and biopsy, followed by treatment of cervical dysplasia. The effectiveness of this approach is dependent on a relatively high level of infrastructure that is not easily established or maintained in the developing world. A study in five African countries revealed that even where the basic infrastructure was in place, very few women were being screened (Chirenje et al. 2001). Even in Latin America, where Pap smear screening programs have been in place for some time, results to date have not shown a significant impact on cervical cancer prevention (Robles 1996; Lazcano-Ponce et al. 1999; Hernandez-Avila 1998). Often, Pap-smear screening programs have not adequately served older women, who have the highest risk of cervical cancer. Pap smear quality and coverage often are low. In addition, even in middle-income countries, program organization to adequately manage, treat, and follow-up women with identified lesions can be a challenge (Sankaranarayanan et al. 2001). Also, Pap tests themselves have shortcomings: high specificity in Pap smear testing cannot be achieved without reducing sensitivity. The WHO Reproductive Health Library includes a summary of a meta-analysis of Pap test accuracy that reviewed 62 studies and concluded "the Pap test may be unable to achieve concurrently high sensitivity and specificity" (Fahey 1995). To address these limitations, a number of new cervical cancer screening approaches are being evaluated, including visual inspection, automated Pap screening, alternative approaches to specimen collection, and protocols using HPV tests (Richart 1995; Spitzer 1998; Manos et al. 1999; Pengsaa et al. 1997; Hillemanns et al. 1999; Sellors et al. 2000; Meijer et al. 2000).

For low-resource settings, there is particular interest in the accuracy and acceptability of visual screening as a means of detecting cervical dysplasia or cancer (Megevand 1996; PATH/Outlook 2000). This type of screening may reduce the cost and complexity of Pap smear screening, and holds the potential for screening and treatment in the same visit. The term "visual inspection" (VI) has been used to refer to methods of examining the cervix for obvious lesions (Nene et al. 1996; Wesley et al. 1997). A study in India comparing unaided VI (also known as "downstaging") and Pap smear results showed that VI had low sensitivity and specificity in detecting cervical dysplasias (Varghese 2000). A second study that assessed downstaging to detect high-grade cervical lesions concluded that neither a low-threshold nor a high-threshold test was adequate for primary screening of cervical lesions (Basu et al. 2002).

A more promising visual screening approach, visual inspection with acetic acid (VIA), is used to describe examination of the cervix after treatment with acetic acid to identify acetowhite lesions. In some settings, visual inspection after acetic acid application may work at least as well as Pap smears. A qualitative summary of the literature reports that in those settings where VIA has been compared to cytology under similar circumstances, VIA has performed as well as, if not better than, cytology in some instances (Gaffikin et al. 2003). Analyses from a growing number of studies in developing-country settings indicate the sensitivity of VIA is equivalent or greater than cytology, although its specificity is somewhat lower (Sankaranarayanan et al. 2004a; Sankaranarayanan et al. 2004b; Basu et al. 2003; Sankaranarayanan et al. 2003; Belinson et al. 2001; Sankaranarayanan et al. 1999; UZ/JHPIEGO 1999; Sankaranarayanan et al. 1998.) Several studies have also evaluated VIA as an adjunctive test for screening in order to increase its specificity. A two-stage screening study in South Africa recommends that VIA be followed by a second, different screening test if the VIA is positive (Denny et al. 2000). An analysis of the data from the Zimbabwe study shows that following VIA with a second screening test, such as an HPV DNA test, improves overall specificity, thus reducing the number of false-positives (Blumenthal et al. 2001).

To complement the growing body of evidence of the accuracy of VIA, a recent study examined the reliability of VIA. The data show moderate to substantial inter-rater reliability for clinicians' assessment of cervical photographs taken after using the acetic acid wash. This reliability statistic is comparable to similar tests of inter-rater agreement for coloposcopy, cervical cytology, and histology (Sellors et al. 2002), and is a significant step toward validating the accuracy of the test.

Other forms of visual inspection, such as visual inspection with acetic acid and low-power magnification (VIAM) and visual inspection with Lugol's iodine (VILI) also are being investigated. VIAM using the AviScope™ device yielded a moderate sensitivity of 60.0 percent for identifying CIN 2, CIN 3, or carcinoma, and a moderate specificity of 69.0 percent in a recent study (Winkler et al. 2003). A second study reported a similar sensitivity of 61 percent and a specificity of 83 percent (Basu et al. 2003). While these results are promising for areas where colposcopy is not available, the clinical utility of the device is still being explored. VILI, which is similar to the Schiller’s iodine test used in the 1930’s has been reevaluated in a recent study as an alternative for use in low-resource settings. Results indicate that VILI has a similar sensitivity and specificity to that of VIA (using a high-threshold cut-off), suggesting it is a promising and suitable alternative to cytology in low-resource settings (Sankaranarayanan et al. 2003). The largest set of pooled data on VILI indicates that it is more sensitive than VIA and at least as specific (Sankaranarayanan 2004b).

Researchers have also been developing mathematical models to evaluate the cost-benefits of alternative screening strategies such as VIA. In a model based on data from Thailand, VIA saved the greatest number of lives and was associated with the least costs, when used to screen women between the ages of 35-55 at five-year intervals and coupled with immediate treatment of positive results (Mandelblatt et al. 2002). A second model based on data from South Africa determined that visual inspection with acetic acid followed by immediate treatment resulted in a 26 percent reduction in cervical cancer incidence and was a cost-savings (Goldie et al. 2001). In addition, a model comparing opportunistic screening to organized screening indicated that greater effectiveness (as determined by the percent reduction in cervical cancer incidence) can be achieved most efficiently if screening is conducted in an organized program and can achieve 80 percent coverage of the population (Adab et al. 2004).

Despite the promising controlled research studies on visual inspection, its application in mass screening programs needs to be carefully considered. Given the potential for overtreatment in a "see and treat" protocol, the complications of treatment in low-resource settings need to be evaluated (Cullins et al. 2000). A recent study in Thailand provides reassurance about the safety of immediate treatment with cryotherapy. When performed by trained nurses, cryotherapy was associated with no major complications and with minimal, unexpected problem visits for minor complications (Gaffikin et al. 2003). (For more information, please see the Treatment Key Issue.) An additional issue that needs to be addressed is the interaction between increasing age and the effectiveness of visual inspection (Zahm et al. 1998).

Other visual screening approaches include cervicography and speculoscopy, but they appear to be less promising for various technical and programmatic reasons (Spitzer 1998; Schneider 1999). A device called a Polarprobe, which evaluates a woman's cervical health by processing electrical and optical properties of cervical tissue, may hold promise (Coppleson et al. 1994; Spitzer 1998).

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Treatment: evaluation of simple approaches

Two outpatient dysplasia treatment approaches have demonstrated particular utility in low-resource settings (Bishop et al. 1995). These are cryotherapy (freezing of diseased tissue through application of a refrigerated probe) and the loop electrosurgical excision procedure (LEEP), which uses a thin electrified wire to excise cervical lesions. These methods have been found to have comparable rates of successes and complications (Mitchell et al. 1998). Cryotherapy is a simple, inexpensive procedure and does not require electricity. Twelve months after treatment, cryotherapy has been associated with cure rates of approximately 80 to 90 percent (ACCP 2003; Andersen and Husth 1992; Olatunbosun et al. 1992). Cryotherapy generally produces a lower cure rate for larger lesions and for lesions that extend into the cervical canal. Complications associated with cryotherapy are minimal, suggesting that offering cryotherapy in settings where women may not have access to follow-up medical care may be a rational approach (ACCP 2003). In addition, cost-effectiveness modeling has shown that cryotherapy is a cost-effective approach compared to other methods such as LEEP, laser ablation, cold knife conization, and total hysterectomy, while still providing an effective treatment (Kleinberg et al. 2003). LEEP, on the other hand, has been associated with cure rates of about 80 to 93 percent (Flannelly et al. 1997; Hulman et al. 1998; Keijser et al. 1992), and may be the preferred method for treating larger, deeper lesions. Compared to cryotherapy, LEEP has been associated with slightly higher rates of complications and side effects such as postoperative bleeding and perioperative pain (Mitchell et al. 1998). The likelihood of cure for both methods decreases with higher-grade lesions and larger lesions. Older age also may be associated with lower cure rates (Mitchell et al. 1998; Paraskevaidis et al. 2000) possibly because older women are more likely to have persistent, higher-grade lesions.

An area of current research interest is whether these treatment approaches can be used in a "see and treat" strategy, in which a client is diagnosed with dysplasia either through a Pap smear, visual screening, or colposcopic exam, and then is treated immediately to remove dysplastic tissue. This approach has been tried in various research settings, including in the United States (Burger et al. 1995) and South Africa, using mobile clinics (Megevand et al. 1996). The approach shows promise because it allows management and treatment decisions to be made in a single visit, reducing the loss to follow-up of many women who may be at high risk (Blumenthal et al. 2001). An evaluation of the single-visit approach using VIA and cryotherapy treatment in Thailand found the approach to be safe, acceptable, and feasible (Gaffikin et al. 2003), with no reported major complication associated with cryotherapy . Unnecessary treatment, however, remains a concern in some settings. Despite the progress in treatment approaches, a global survey found that clinicians in developing countries still rely heavily on invasive inpatient methods, such as cone biopsy and hysterectomy, and in many places all degrees of cervical dysplasia were treated (Bishop et al. 1996).

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Role of HPV tests in cervical cancer prevention

Research is ongoing to determine acceptable protocols for testing for the human papillomavirus (HPV) as part of a cervical screening and treatment strategies. Proposed uses of HPV testing in cervical cancer prevention programs include:

  1. Where Pap smear screening is the norm, as a triage for women with Pap smear findings of atypical squamous cells of unknown significance, that is, cells that are atypical but not definitely dysplasia (women who test positive for high-risk HPV types would be monitored closely or referred for colposcopy).
  2. As a means of surveillance of women after treatment for high-grade lesions or microinvasive cancer (those who test positive for high-risk HPV types would be monitored more closely than those who test negative).
  3. Among women aged 30 to 35 or older (those who test positive for high-risk HPV would undergo diagnosis via colposcopy or another visualization technique) (Cuzick 2000).

In general, however, proposed approaches such as administering HPV tests to women with mild dysplasia in order to determine whether treatment is necessary have had varying levels of effectiveness and are likely to be relatively costly (Bollen et al. 1997; Kaufman et al. 1997; Lytwyn 2000).

Persistent HPV infection appears to be a clear risk factor for persistent cervical intraepithelial neoplasia (CIN II) (Ho et al. 1995), and type-specific persistence of high-risk HPV infection is a good predictor of developing high-grade lesions (Kjaer et al. 2002). HPV appears to be a stronger predictor of persistent cervical abnormalities in women over age 35 (Spitzer 1998). Certain types of HPV and persistent high loads of viral infection may be associated with increased risks of cervical neoplasia (Ylitalo et al. 2000; Joseffson et al. 2000), but whether this justifies HPV DNA screening is still open to debate (Johnston 2000; Elfgren et al. 2000). HPV remains detectable longer than cervical cytologic abnormalities, suggesting that HPV DNA testing may be a more sensitive test for HPV infection and that there may be a role for HPV- DNA testing in women with ambiguous cytology results (Schiffman et al. 2002).

Recently, work has been published evaluating use of HPV DNA testing for primary screening for cervical cancer, particularly in low-resource settings.� A study in Costa Rica, for example, assessed test cut-off points and the importance of women's age on test effectiveness at detecting high-grade cervical lesions or cancer (Schiffman et al. 2000). Research on HPV testing has included assessments of the accuracy and acceptability of different sampling methods with the expectation that self-sampling methods could help increase participation in cervical cancer screening. A study in South Africa found that HPV DNA testing using self-collected vaginal samples performed quite well compared to conventional Pap screening in that setting (Wright et al. 2000; Denny et al. 2000). Women participating in a study in Mexico overall rated self-collected samples for HPV as more acceptable than traditional Pap smear screening (Dzuba et al. 2002). A study in Zimbabwe evaluated HPV-based screening in a population at high risk for HIV infection (Womack 2000). Specificity remains a concern with use of HPV testing for primary screening, however, and more research is needed to determine optimal approaches (Cuzick 2000; Koss 2000). One study in South Africa suggests that specificity can be improved by adjusting the level of HPV DNA used to define a positive result (Kuhn et al. 2000).

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The promise of HPV vaccines

Prospects are hopeful for the utility of HPV vaccines. Products currently in development include prophylactic vaccines (which would prevent HPV transmission) and therapeutic vaccines (which would cause the disease to regress or prevent dysplasia from progressing). Prophylactic vaccines that protect against HPV infection, if administered before the initiation of sexual activity, would prevent women from developing cervical cancer later in life. A therapeutic vaccine, theoretically, could help women already infected with HPV.

HPV immunization would offer a long-term solution to cervical cancer especially in developing countries, where it is especially difficult to effectively implement screening and treatment programs that reduce cervical cancer deaths. Both prophylactic and therapeutic approaches show promise, given the epidemiology and natural history of HPV-related disease, and natural immunity against HPV (Coursaget and Muñoz 1999; Duggan-Keen 1998; Lowy and Schiller 1998). Commercial vaccines are unlikely to be available for some years, and their effect on cervical cancer rates would not be measurable for years after their introduction. However, they have the potential to sharply reduce the incidence of cervical cancer (Jones 1999; Galloway 1998). For example, modeling of the clinical impact of vaccine introduction suggests that if a vaccine was introduced that was 98 percent effective against HPV type 16 and 18 infection, a 98 percent reduction in cancers associated with those two HPV types and a 51 percent reduction in total cancers could be expected, provided that coverage of the population of adolescent women was 100 percent (Goldie et al. 2003). An experimental vaccine targeting HPV type 16, which is associated with approximately half of all cervical cancers, is very promising. In a controlled trial the vaccine proved to be 100 percent effective in protecting against persistent HPV type 16 infections and associated precancerous cervical lesions (Koutsky et al. 2002).

When a commercial vaccine does become available, immunization programs will need to address the challenge of positioning the vaccine so that it will be acceptable to young women. A woman’s attitude about receiving an HPV vaccine is affected not only by her own risk behaviors but by such variables as knowledge of HPV, feelings about vaccinations in general, and perception that others approve of vaccination to affect (Kahn et al. 2003).

Although there is evidence that immune response does play a role in controlling HPV infections, it is not really known why HPV infections persist in some individuals and regress naturally in others (Duggan-Keen 1998; Galloway 1998). The distribution of HPV types varies substantially by geographic region. In Kenya, for example, the pattern of HPV types has been reported as different than in other regions, indicating that further research will be necessary to appropriately identify these regional differences in HPV prevalence (De Vuyst et al. 2003). Preventing a majority of cervical cancer cases therefore will require a multivalent vaccine that is effective against a combination of common HPV types (Galloway 1998).

Even with the most optimistic assumptions about when a prophylactic or therapeutic vaccine will become available, many hundreds of thousands of women will develop cervical cancer in the coming decades. Therefore, it is important to continue developing appropriate screening and treatment programs for precancerous lesions. For more information on HPV vaccine development, see PATH�s paper HPV Vaccines: Promises and Challenges (www.path.org/resources/cxca_publications.htm).

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Cervical cancer and HIV

Cervical cancer is an important AIDS-related disease in women. Since 1993, the disease has been considered an AIDS-defining illness in women infected with HIV. Studies have established a higher prevalence of HPV infection among HIV-positive women compared to HIV-negative women; women with HIV infection are at risk of more virulent HPV infections and more rapid progression from infection to neoplasia (Abercrombie and Korn 1998; Luque et al. 1999). HIV and HPV-infected women also are more likely to have dysplasia than women infected with either virus alone (La Ruche et al. 1998). Furthermore, there is evidence suggesting that the higher prevalence of HPV among HIV-seropositive women reflects persistence or reactivation of pre-existing HPV infection rather than recent acquisition of new infection (Palefsky 1999).

Cervical dysplasia is common in women with HIV infection; those who are more severely immunosuppressed appear to be at a higher risk for dysplasia and neoplasia (Leroy et al. 1999; Fruchter et al. 1998; Abercrombie and Korn 1998). Studies have found that the prevalence of dysplasia among HIV-infected women ranges from 31 to 63 percent, and HIV-positive women are almost five times more likely to have dysplasia than HIV-negative women. In addition to having a higher prevalence of cervical dysplasia, women with HIV tend to have larger lesions, more advanced dysplasia, and more vulvovaginal lesions than do HIV-negative women. Dysplasias can be persistent, progressive, recurrent, and difficult to treat in women with HIV (Abercrombie and Korn 1998; Tate and Anderson 2002). In addition, recent research suggests that vitamin A deficiency may play a role in the development of squamous intraepithelial lesions (SILs) in HIV-positive women (French et al. 2000). Less is known about the interaction between HIV and invasive cervical cancer. There is evidence to suggest that HIV-positive women with invasive cervical cancer are approximately 10 years younger than their counterparts who are HIV-negative (Gichangi et al. 2003). A large proportion of HIV-positive women with invasive cervical cancer may have acquired the infection after the start of abnormal cell changes (Fruchter et al. 1998). However, several studies in Africa suggest that although SILs (both low-grade and high-grade) are more common in HIV-positive women, the lesions may not advance to the invasive cervical cancer stage (Chirenje et al. 2002; La Ruche et al. 1998). This may be due, in part, to women succumbing to other HIV-related opportunistic infections before invasive cervical cancer develops (Chirenje et al. 2002).

The most effective methods of screening and treatment of dysplasia in HIV-infected women are under study. Current recommendations are to screen HIV-positive women every 6 months with a Pap smear and refer for colposcopy any women who has atypia or dysplasia on her Pap smear (Abercrombie and Korn 1998). Recent evidence has shown a dramatic increase in HIV shedding in HIV-positive women treated for precancerous lesions, highlighting the importance of abstaining from sexual intercourse while the cervix heals to reduce the risk of transmitting HIV to the partner (Wright et al. 2001).

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Client perceptions

Research on how clients and health care providers perceive cervical cancer and the factors that contribute to client decisions to seek out cervical cancer screening treatment is crucial to the success of cervical cancer prevention programs. Many studies have shown that women in developing countries and other underserved populations lack information on cervical cancer and available services (Adanu 2002; Ajayi and Adewolfe 1998). Other factors reducing women's participation in cervical screening programs include poor awareness of the indications and benefits of the cervical smear test; lack of knowledge of cervical cancer and its risk factors, fear of embarrassment, pain, or cancer; anxiety caused by receiving an abnormal cervical smear result; and poor understanding of cervical screening procedures (Holroyd et al. 2004; Fylan 1998; Jameson et al. 1999). Women may face multiple barriers, including a lack of trust in health care providers, competing priorities due to extreme poverty, culturally biased attitudes toward cancer, and a general rejection of the pelvic exam (Lazcano-Ponce 1999; Masood 1999).

To overcome barriers such as these, studies have tried to assess various strategies for raising women's awareness of cervical cancer prevention and for increasing women's participation in screening programs. For example, a study in Brazil reported using interviews on a popular radio program, broadcasting messages by loudspeaker in neighborhoods, and having nurses visit homes to talk with women. Health center hours were flexible and available in the evenings and on weekends, and screening was offered in the woman's home if she could not get to the nearest health center (Mauad et al. 2002). A study in Mexico found that women who have had a positive prior experience with health services and providers were more likely to seek screening services. In areas where screening programs have low coverage, it may be beneficial to focus on improving the quality of care as a means of increasing utilization of screening services (Lazcano-Ponce et al. 2002). Other researchers are assessing whether using self-collection methods instead of pelvic examinations may make cervical cancer screening more acceptable to women. Self-sampling can be done in the woman's home, offering her increased privacy and less pain and embarrassment (Dzuba et al. 2002). (For more on self-sampling, see the section on the role of HPV tests, above.)

In recent years, there has been much interest in the psychological consequences of receiving an abnormal cervical smear and colposcopy. Studies have found that low levels of information, coupled with poor communication between patients and health professionals, contribute to high levels of negative psychological consequences (including emotional distress, uncertainty, and perceived inability) in women with abnormal cervical smear results (Fylan 1998; Lauver et al. 1999). These psychological consequences are associated with nonattendance and delay in seeking follow-up services for abnormal smear results. Clinical interventions that foster and promote coping strategies such as acceptance, relaxation, and diversion can help reduce psychological distress associated with the experience of having an abnormal smear result (Lauver et al. 1999).

Studies also show that health care providers are in need of effective technical training in cervical dysplasia screening/treatment and training in educating and counseling clients at risk of cervical cancer (PATH 1996; Strickland et al. 1996.)� Increased availability of better information and educational materials through a variety of channels may help reduce the anxiety and stress caused by receiving a positive Pap smear result (Idestrom et al. 2003). Successful intervention strategies to promote cervical cancer screening have included mass media campaigns, outreach programs, mobile examination rooms, and personalized letters to patient populations (Marcus and Crane 1998; Masood 1999; Tatum et al. 1997).

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