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895 Special Articles CYTOLOGICAL SCREENING OF 1000 WOMEN FOR CERVICAL CANCER A Report by the South-East Scotland Faculty of the College of General Practitioners * * The following general practitioners took part in this investiga- tion: I. A. D. ANDERSON, A. FRASER DARLING, B. C. HAMILTON, J. GOODBRAND, G. IRVINE, E. V. KUENSSBERG, LOWELL LAMONT, A. H. D. LARGE, A. R. LAURENCE, S. LIPETZ, D. MURRAY, R. MACGREGOR, D. MCVIE, D. W. MACLEAN, G. MACNAUGHTAN, M. W. Moss, C. E. MUNRO, H. NEVE, M. PEARSON, A. D. ROBERTSON, R. SCOTT. THIS report shows that the cytological detection of early cervical carcinoma can be undertaken in general practice. In this country until now cervical smears have been taken only from groups of hospital patients, from patients attending contraceptive clinics, and from gynaecological outpatients. Papanicolaou and Traut’s 1943 paper on exfoliative cytology demonstrated that cancer cells desquamate from a neoplasm of the cervix. During the past fifteen years or so it has become generally accepted that cervical cancer can be detected as an early preinvasive lesion in the squamous epithelium of the external os. (This pre- TABLE I-ANALYSIS OF UNSUSPECTED POSITIVES ACCORDING TO THE INDICATION FOR TAKING THE SMEAR invasive cancer is also known as intraepithelial cancer or carcinoma-in-situ.) It has been shown by Petersen (1956) that about a third of these lesions can develop into invasive cancers. The average age in early cases detected by cytological examination is about 38, whilst the average age of presen- tation for all stages of clinically obvious cervical cancer is 48 years. It seems reasonable to assume that the ten years gained in diagnosis may be of considerable importance. The Investigation In 1955 Prof. R. J. Kellar invited the South-East Scotland faculty to take part in a research project on the early detection of cervical cancer. The general prac- titioners were instructed in the use of a wooden Ayre spatula and the fixing of slides. The slides were sent, with a note of the details of each case, to Professor Kellar’s department. The general practitioners taking part in this investiga- tion took cervical smears during their ordinary consulting hours from three groups of patients: (1) All women who came for.,postnatal examination. (2) As many women as possible who had menopausal problems without histories pointing to any disease of the genital organs. (3) As many women as possible in whom a complete medical examination was indicated for any reason other than gynecological complaints, or women seeking advice on family planning. TABLE II-UNSUSPECTED POSITIVES CLASSIFIED BY AGE-GROUPS Results Tables 1-111 summarise our findings. " Unsuspected positives " were patients who had a healthy cervix clinically (on inspection and palpation) but whose cervical smear was reported as suspicious or frankly malignant. The average age of " unsuspected positive " cases was 35-5 years; of the 7 patients who underwent hysterectomy 37 years; of patients who required amputation of the cervix 36 years; and of those still under surveillance after ring biopsy 32-2 years. Table ill does not show the time interval between the first suspicious smear and the final diagnosis and opera- tion, and it does not give all the grounds on which the final decision to operate rested. In most cases several repeat smears and biopsy specimens were taken. In cases 1-4 the biopsy was in itself sufficient to eradicate the whole suspected area: subsequent cervical smears showed no abnormal cells. Similarly, in cases 5-8. amputation of cervix removed the cancer. TABLE III-HISTOLOGICAL DIAGNOSIS AND SUBSEQUENT HISTORY OF UNSUSPECTED POSITIVES

CYTOLOGICAL SCREENING OF 1000 WOMEN FOR CERVICAL CANCER *1A Report by the South-East Scotland Faculty of the College of General Practitioners

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Page 1: CYTOLOGICAL SCREENING OF 1000 WOMEN FOR CERVICAL CANCER *1A Report by the South-East Scotland Faculty of the College of General Practitioners

895

Special Articles

CYTOLOGICAL SCREENING OF 1000

WOMEN FOR CERVICAL CANCER

A Report by the South-East Scotland Faculty of theCollege of General Practitioners *

* The following general practitioners took part in this investiga-tion: I. A. D. ANDERSON, A. FRASER DARLING, B. C. HAMILTON,J. GOODBRAND, G. IRVINE, E. V. KUENSSBERG, LOWELL LAMONT,A. H. D. LARGE, A. R. LAURENCE, S. LIPETZ, D. MURRAY, R.MACGREGOR, D. MCVIE, D. W. MACLEAN, G. MACNAUGHTAN,M. W. Moss, C. E. MUNRO, H. NEVE, M. PEARSON, A. D.ROBERTSON, R. SCOTT.

THIS report shows that the cytological detection of earlycervical carcinoma can be undertaken in general practice.In this country until now cervical smears have been takenonly from groups of hospital patients, from patientsattending contraceptive clinics, and from gynaecologicaloutpatients.Papanicolaou and Traut’s 1943 paper on exfoliative

cytology demonstrated that cancer cells desquamate froma neoplasm of the cervix. During the past fifteen years orso it has become generally accepted that cervical cancercan be detected as an early preinvasive lesion in thesquamous epithelium of the external os. (This pre-

TABLE I-ANALYSIS OF UNSUSPECTED POSITIVES ACCORDING TO THE

INDICATION FOR TAKING THE SMEAR

invasive cancer is also known as intraepithelial cancer orcarcinoma-in-situ.) It has been shown by Petersen (1956)that about a third of these lesions can develop into invasivecancers.

The average age in early cases detected by cytologicalexamination is about 38, whilst the average age of presen-tation for all stages of clinically obvious cervical cancer is48 years. It seems reasonable to assume that the ten yearsgained in diagnosis may be of considerable importance.

The InvestigationIn 1955 Prof. R. J. Kellar invited the South-East

Scotland faculty to take part in a research project on theearly detection of cervical cancer. The general prac-titioners were instructed in the use of a wooden Ayrespatula and the fixing of slides. The slides were sent, witha note of the details of each case, to Professor Kellar’sdepartment.The general practitioners taking part in this investiga-

tion took cervical smears during their ordinary consultinghours from three groups of patients:

(1) All women who came for.,postnatal examination.

(2) As many women as possible who had menopausalproblems without histories pointing to any disease of thegenital organs.

(3) As many women as possible in whom a completemedical examination was indicated for any reason other thangynecological complaints, or women seeking advice on familyplanning.

TABLE II-UNSUSPECTED POSITIVES CLASSIFIED BY AGE-GROUPS

ResultsTables 1-111 summarise our findings. " Unsuspected

positives " were patients who had a healthy cervix

clinically (on inspection and palpation) but whose cervicalsmear was reported as suspicious or frankly malignant.The average age of " unsuspected positive " cases was

35-5 years; of the 7 patients who underwent hysterectomy37 years; of patients who required amputation of thecervix 36 years; and of those still under surveillance after

ring biopsy 32-2 years.Table ill does not show the time interval between the

first suspicious smear and the final diagnosis and opera-tion, and it does not give all the grounds on which thefinal decision to operate rested. In most cases several

repeat smears and biopsy specimens were taken. In cases1-4 the biopsy was in itself sufficient to eradicate the wholesuspected area: subsequent cervical smears showed noabnormal cells. Similarly, in cases 5-8. amputation ofcervix removed the cancer.

TABLE III-HISTOLOGICAL DIAGNOSIS AND SUBSEQUENT HISTORY OFUNSUSPECTED POSITIVES

Page 2: CYTOLOGICAL SCREENING OF 1000 WOMEN FOR CERVICAL CANCER *1A Report by the South-East Scotland Faculty of the College of General Practitioners

896

The following case-history illustrates the routine

procedure:In January, 1956, at a postnatal examination a positive smear

was obtained in case 9. This was repeated in hospital and ontwo subsequent occasions in 1956. However, the patientbecame pregnant during this period of observation and wasallowed to continue with her pregnancy. Postnatal examination

yielded a further positive smear and a hysterectomy wasfinally performed in December, 1957, and the diagnosis ofinvasive cervical cancer was thus confirmed.

Discussion

Early fears that the Ayre technique would take up toomuch time, or that it would be resented by the patients,proved groundless. The operation was easily performedafter a little practice, and very few slides had to be

repeated because they were technically unsatisfactory.The smear was not intended to take the place of gynaeco-logical investigation by a specialist. When the history orphysical examination was suspicious, the patient wasreferred to a gynaecologist even if the cervical smear wasnegative. Similarly, if the family doctor received a

suspicious report on a smear taken from a clinically un-suspected cervix, he referred the patient for further

investigation.Before the general practitioners became accustomed to

examining the cervix visually as well as manually theymay have had some difficulty in deciding whether or notthe cervix looked suspicious. However, in all the 15 casesdiagnosed on cytological grounds alone the gynaecologistconfirmed that there was nothing clinically abnormal.

Admittedly this series of 1000 cases is still small,but the finding of 15 clinically unsuspected positives andof another 5 atypical cases is worth noting. In Britishseries of hospital or special-clinic patients the incidencehas been about half as high (Royal College of Obstetriciansand Gynxcologists 1955); and in field-surveys in Georgia,Tennessee, and at the special cancer-prevention clinic inNew York the proportion of clinically unsuspectedpositives was even lower (Erickson et al. 1956, Scapier etel. 1952). An incidence of approximately 2% in womenattending for postnatal examination in the presentinvestigation suggests that routine screening of this groupis especially desirable.For several reasons the average age of women who

have their babies at home is slightly greater than that ofwomen who are admitted to hospital. This may have

given prominence in this series to the age-group 30-40which included most unsuspected positives; but thisunderlines rather than detracts from the need for greatervigilance.

It has been said that pregnancy changes in the cervicalendothelium are often suspicious but that they regressspontaneously after parturition. All postnatal positivesmears in this series were still positive three to six monthsafter delivery. In none of our cases was there spontaneousregression, and treatment was eventually required in allbut one. (The exception was case 1, who has now beenfollowed up for two and a half years.)

In the minds of those who have taken part in this

investigation there is no doubt whatever about the valueof the smear as a routine screening-test: it should be

part of every pelvic examination. It was particularlysignificant to find positive cases in the 30-40 age-group:this suggests a possible lag of ten to twelve years betweenthe first positive smear and the appearance of a clinicallydetectable cervical carcinoma. Such a latent period hasbeen demonstrated experimentally by Foulds (1951).

SummaryCervical smears were taken from 1000 women. 15

unsuspected positives for early carcinoma were found-ahigher incidence than in previous hospital studies.To take such smears in general practice is simple and

reliable. Cytological reports on such smears should beavailable to all general practitioners.We are greatly indebted to Professor Kellar and his staff, in

particular Dr. A. F. Anderson who examined the smears, in collabora-tion with Miss R. MacBryde and Miss K. Cockburn, for theirconstant advice and encouragement. We are also grateful forthe helpful advice of Mr. S. A. Sklaroff, lecturer in the departmentof public health and social medicine, Edinburgh University. A

grant was provided by the Scottish Advisory Committee on MedicalResearch.

REFERENCES

Erickson, C. C., Everett, B. E., Jr., Graves, L. M., Kaiser, R. F., Malmgren,R. A., Rube, I., Schreier, P. C., Cutler, S. J., Sprunt, D. H. (1956)J. Amer. med. Ass. 162, 167.

Foulds, L. (1951) Ann. R. Coll. Surg. Engl. 9, 93.Papanicolaou, G. N., Traut, H. F. (1943) Exfoliative Cytology.Petersen, O. (1956) Amer. J. Obstet. Gynec. 72, 1063.Royal College of Obstetricians and Gynæcologists (1956) Report of confer-

ence. J. Obstet. Gynœc., Brit. Emp. 1956, 53, 3.Scapier, J., Day, E., Dunfee, C. R. (1952) Cancer, 5, 315.

A HOSPITAL WORKSHOP *

W. V. WADSWORTHM.B., B.Sc. Manc., M.R.C.P., D.P.M.

MEDICAL SUPERINTENDENT

R. F. SCOTTB.A. Lond., Dip. Psych.

MANAGER OF REHABILITATION UNIT

W. L. TONGEM.D. Manc., D.P.M.

DEPUTY MEDICAL SUPERINTENDENT

CHEADLE ROYAL HOSPITAL, CHESHIRE

* Abridged from paper to the Royal Medico-Psychological Associa-tion on April 30, 1958. The Nuffield Provincial HospitalsTrust have given a grant to cover research on this project.

ALL the different types of sheltered hospital workshopsso far established in this country have had to contendwith two difficulties: first, they have been completelydependent on a continuous even supply of suitablematerial from outside industry, and secondly, they havefound it hard to provide chronic psychotic patients withsimple assembly work in sufficient variety. Our ownindustrial unit, started two years ago, has on the wholebeen successful and has raised many interesting points.For instance, though the patients were all doing the samework of assembling umbrellas, or should have been

doing the same work (for they were all producing the sameend-product), differences in practice crept in, though astandard method was taught originally. Such differences

may appear slight and superficial, but when taken withtempo of work, they could easily account for almost allthe variation in earnings between patients. On a straightpiece-work basis, it is speed, used effectively, that governsthe size of the pay-packet. The twin principles offinancial payment and speed lift the work done by patientsinto the same category as work done by outside healthyworkers-in distinction from traditional occupationaltherapy, which, by definition and association, is onlydone by those ill enough to remain in hospital.

SETTING NORMAL STANDARDS

The problem is, in part, one of communicating to thepatients normal outside standards of tempo, which in theleisured setting of occupational therapy have little