CHAPTER 4: SCREENING FOR CERVICAL CANCER

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88Chapter 4: Screening for Cervical Cancer4Chapter 4: Screening for Cervical CancerScreening family planning clientsOpportunistic cervical cancer screening is often integrated into family planning services.Family planning counselling provides a good opportunity to discuss the benefits of cervicalcancer screening and a gynaecological examination is often more easily accepted duringa reproductive health consultation. Screening should be encouraged and performed onclients of family planning services within the target age group. Contraceptive users do notneed to be screened more often than other women, regardless of the method they use.Screening women with a reproductive tract or sexually transmitted infection (RTI/STI)Women in the target age group who present to health facilities with complaints suggestiveof RTI/STI should be examined. They should be screened for cervical cancer only if there isno visible acute infection. If the speculum examination reveals evidence of acute infection,appropriate treatment should be given and cervical cancer screening should be deferreduntil after the infection has resolved.Health education and counselling on RTI/STI should include information on HPV infection,its relation to cervical cancer, and the protection offered by safer sex behaviours, includingcondom use. Male partners too should be treated, and counselled on cervical cancerprevention. STI services aimed primarily at men should include information on HPV andcervical cancer prevention.Other opportunities for cervical cancer screeningWomen at the end of their reproductive years are at greatest risk of cervical cancer,particularly if they have never been screened. They tend to use reproductive healthservices less often than younger women, but may use other health services, e.g. formanagement of hypertension, heart disease, diabetes or infectious diseases. In addition,women in the target age group may come to a health facility with a child or relative whoneeds services. All women in the target age group who visit a facility for any reasonshould receive information and be encouraged to come for screening (see also Chapter3). General medical services at primary, secondary and tertiary levels can provide cervicalcancer screening for such women, using on-site, trained providers. If this is not possible,women should be given health education and referred to a convenient screening clinic.No missed opportunitiesCervical cancer screening programmes should also try to reach all women in thetarget age group who have contact with the health system for any reason.
Chapter 4: Screening for Cervical Cancer 89Choice of screening test to be usedThe choice of screening test or tests to be used is usually made at the national orregional level. Nevertheless, providers should have some basic knowledge of all theavailable screening tests.Decisions on the test or tests to be used may be based on:• the organization of the health system;• the funds available;• the number and type of health workers;• the availability of laboratory services and transport;• the availability and cost of the various screening tests.The test used may also be determined based on the physical proximity of services towomen; for example, it might be decided to use the Pap smear (which requires womento return for their test results) in urban areas and visual inspection with acetic acid (VIA)(for which results are immediately available) in more inaccessible rural areas in thesame country.The most extensive and long-term experience in cervical cancer screening is withcytology, which has been used in numerous countries since the 1950s. Cytology-basedscreening and treatment programmes have reduced cervical cancer incidence andmortality by as much as 80% in Canada, the USA and some Nordic countries, and by50–60% in other European countries.It has been difficult to replicate this success in low-resource settings, because of theinherent requirements of a cytology-based programme. These include highly trainedpersonnel, well equipped laboratories, transport of specimens, and an effective systemfor collecting information and following up patients. In addition, the demands of othercompeting health needs often result in a lack of resources or political will to makecervical cancer screening a priority.Because of the problems of implementing quality cytology-based screening, alternativemethods, such as visual inspection, have been developed. These methods have shownpromise in controlled research settings but have not yet been widely implemented.Their ultimate impact on cervical cancer incidence and mortality will not be known untillarge ongoing population-based studies are completed. HPV-based tests are now alsocommercially available, but have disadvantages, including the need for sophisticatedlaboratory facilities and high cost.4Chapter 4: Screening for Cervical Cancer
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CHAPTER 4: SCREENING FOR CERVICAL CANCER

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