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Cytologic Screening Programs
Features of Successful Screening Programs
The success of cervical cancer screening is shown by its ability to
reduce the incidence of cervical cancer and the resulting mortal-
ity, in a cost-effective way. To be successful it is fundamental that
the program is organized and broad-based, developing along
the line of care for cervical cancer. All the stages involved in the
finding of the women, the collection of material for the cytolog-
ical test, transport and processing of the slides, identification of
lesions, and finally the delivery of results, treatment, and follow-
up of the women with alterations should happen in sequence,
synchronized and with the highest quality. Any failure in one
of these stages can compromise the impact of the screening on
the health of the population. The following are some aspects of
successful screening programs:
Government policy:
Planning within a governmental
policy and national planning for cancer control. This
includes the definition of the age range of the popula-
tion to be prioritized and the frequency (interval) of
screening, apart from production of instructions to
guide the process, including recommendations regard-
ing nomenclature and the therapeutic action for the
lesions identified.
Coverage:
Measures to guarantee good coverage, with
special attention to identification of women in the tar-
get population. Education of these women regarding
cervical cancer screening can contribute to increased
attendance and confidence in the procedure, apart
from facilitating understanding of the results of the
cytological test.
Integrated system:
The different levels of healthcare in
the program should be integrated like a network, with
the capacity to ensure continuity of the care within the
different levels.
Health professionals:
Good results can be achieved
by educating and training the health professionals,
improving the attention given to the women, the qual-
ity of samples collected, the quality of the screening
and the results of the tests, and also the research and
follow-up of the patients with lesions needing treat-
ment.
Quality o f the diagnosis:
Efficient and high-quality labo-
ratory service, which should preferably be centralized;
quality control of cytology reading.
Infrastructure o f health services:
Adapting the services
to give the treatment needed, with the capacity for
attending to the planned demand, in relation both to
equipment, installations, and material and to the hu-
man resources available. It is of fundamental impor-
tance to guarantee the supply and the accessibility of
the health services.
Information system:
An integrated information system
linking the different elements of the program, permit-
ting identification of each woman and the exchange
of management information, and monitoring and
referring women with results showing alterations to
the respective health services, with a view to ensuring
that these patients receive appropriate diagnosis and
treatment, should be achieved.
Indicators:
Monitoring and evaluating cervical cancer
prevention programs is essential for effective, efficient
planning and service organization, as well as for
patient management. Indicators created to evaluate
performance at the different stages of the program
should be monitored regularly, using information
generated preferably through the routine information
system.25
Leadership:
Leadership, management skills, attention
to linkages at all levels of the program, and budgeting
skills are essential.8
Limitations of Screening Programs
Limitations of prevention programs can be related to different
factors, such as errors and failures in the program as well as
socioeconomic and cultural problems.
Errors and Failures in the Program
The first limitation refers to the Pap test. Although it is the most
effective screening test in oncology, it shows failures with low
sensitivity where the false-negatives vary between 3 and 13%,
and high specificity, with false-positives less than 5%.
Achieving the ideal coverage is another problem that lim-
its screening programs. For a prevention program to diminish
cervical cancer mortality it must achieve a coverage estimated at
around 80% of the women, so this must be the target. For this
the community must be mobilized and informed in order to
make the women realize the causes and consequences of cervi-
cal cancer and so submit to the tests. The warnings should be
spread through all means of communication including explana-
tory folders and pamphlets. Lack of knowledge becomes one of
the main allies of the inefficiency of screening programs. Strate-
gies must be established to encourage regular participation of
women in the program and the return of women with abnormal
results. Around 29% do not return after taking the test.36 Some
measures that can help are assistance with transport, slides/
films, and personal letters with folders. It is very important to
individualize the incentives according to the socioeconomic
level of the patients.
Other causes of failures in the programs include inadequate
collection of material to be examined, errors of interpretation
in the cytopathology lab, absence of adequate follow-up, and
failures in the treatment of precursor lesions. It becomes fun-
damental to keep the multidisciplinary teams who work with
prevention stimulated and up to date, aware of the importance
of each stage and its role in achieving the final result, which is to
avoid death by cervical cancer.
Socioeconomic and Cultural Problems
Limitations that extrapolate the limits of the program and for
this reason can be considered as extrinsic also occur. In this group
are political limitations, as mainly in developing countries other
questions could be prioritized and oppose the prevention of cer-
vical cancer just as with survival, infectious/contagious diseases
such as tuberculosis or AIDS, vaccination, or the fight against
hunger and bad nutrition.
Sociocultural and behavioral questions can also be a negative
influence in the running of programs and should be detected
and minimized. This group includes the level of education of
the women that could influence directly actions and response to
the programs, religious aspects, and the decisive influence of the
companion on the woman, contributing to diminish women's
adhesion to the screening programs.
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