PART ONE
General Cytology
Age standardized (World) rate (per 100,000)
<9.3
<16.2
<26.2
<32.6
<87.3
lesions.11
Although this morphology-based model of a con-
tinuum has now been supplanted by a more discrete theory of
multistage carcinogenesis, the cervical intraepithelial neoplastic
scale still merits consideration as the current basis of clinical
management.12
Cervical cancer screening is an example of success in the pre-
vention of cancer. Unfortunately the majority of women who
develop cervical cancer live in countries where there is a lack of
infrastructure to support the organization and management of
programs, or where other obstacles such as social and cultural
questions make their participation difficult. Permanent efforts
to find new and more effective strategies will be necessary to
expand the access and participation of these women, optimizing
resources and modifying the mortality statistics for the disease,
mainly in these areas.
Cervical Cancer Incidence and Mortality
Worldwide
Currently cervical cancer is potentially curable, but still continues
to be the second most frequent cause of death by neoplasia in
women and the survival rate in 5 years varies from 44 to 66%.13
The highest incidence occurs in Latin America, the Carib-
bean, Africa (tropical sub-Sahara), and South and Southeast
Asia8 (Fig. 3.1). Around 80% of the cases occur in developing
countries and just 20% in developed countries. Socioeconomic
and cultural aspects are a factor in this unequal distribution of
this neoplasia around the world. However, a preponderant fac-
tor in the areas of low incidence is the level of information from
the feminine population regarding the disease and the continual
screening of this population. On the other hand, in developing
countries, the low level of awareness of the problem, the lack of
interest of the sanitary authorities, and the use of opportunist
screening favors the continuance of this unfavorable situation
and indicates the urgent need for the public health authorities
to find a solution.
An important number of risk factors for cervical carcinoma
have been identified and can therefore be controlled, avoiding
the progress of pre-neoplastic lesions. These factors are early
start to sexual activity, multiple partners, the number of part-
ners a man has, infection by oncogenics HPV, precarious genital
hygiene, and smoking.
Histologically the largest number of cases is of squamous
cell carcinoma; however, the incidence of cervical adenocarci-
noma has gradually increased over the past decades, particu-
larly in young women, where it has doubled.14 A larger number
of adenocarcinomas are being identified, either by control of
cervical cancer in developed countries or by association with
HPV infection, above all the type 18.
Programs applied in Scandinavian countries and in Canada
demonstrate that with continuous screening, it is possible to
reduce mortality from cervical cancer by almost 75%. However,
the reduction of the mortality rate is necessarily related to the
real efforts by doctors and population, the frequency and qual-
ity of the specimen collection, the examination and diagnostic
analysis, adequate communication between the specialists, and
the efficacy of the system for management of the patients.15
Efficacy of Screening
The efficacy of cytological screening for cervical cancer depends
on the possibility of modifying the course of the disease through
identification of women with high-degree precursor lesions and
invasive initial lesions. With this it is possible to distinguish the
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