Pap smear, colposcopy and biopsy findings at follow-up of Pap smear positive women in North-east Thailand.

As part of an ongoing project involving a large cohort in the Khon Kaen Province in the North-east of Thailand, a total of 236 women who had tested positive for a Pap smear at the initial recruitment and advised to seek medical attention were followed up after a mean period of 3.1 years. The 204 individuals who could be contacted were interviewed to determine treatments received and underwent a further Pap smear as well as colposcopy in 179 of the cases. On clinical advice, biopsies were also taken from 32 of these. Only 15% of the total of 204 had actually received therapy, the majority undergoing surgery (self-reported). Possible positive Pap smear results were obtained for 23.5%, with 6.4% having high grade squamous intraepithelial lesions (HGSILs) or squamous cell carcinoma (SCC) (one case). Comparison of the different testing modalities demonstrated 5.6% false negatives and 16.2 false positives for the Pap smear with colposcopy as the gold standard. Compared with biopsy findings, there were 21.8% and 40.6% false positives with Pap and colposcopy, respectively, but no false negatives. The present results point to good efficacy for the initial screening, since only 0.5% of the total population developed an SCC. However, judgement as to therapy should depend on a biopsy since there were considerable false positives with the other two modalities employed.

Consistency of cytology diagnosis for cervical cancer between two laboratories.

The principal approach to the prevention of cancer of the cervix uteri has been through screening programmes, using the cervical smear (Pap test) to detect precursor lesions. The sensitivity and specificity of Pap smears depend on the skill of the observer in recognizing and classifying a variety of cellular abnormalities. We have studied the reproducibility of cytological diagnosis, according the Bethesda classification, made by cytologists in Khon Kaen, north-east Thailand, and in Helsinki, Finland, on smears taken from rural women undergoing screening during 1994-2001. A total of 313 slides were reviewed. The prevalence of abnormalities was relatively high, since the series included smears judged abnormal in Khon Kaen or from women who developed cancer during follow-up, as well as a group whose smears were negative. In general, the reviewing cytologist in Finland evaluated more slides as abnormal than in the initial report. The level of agreement between the two observers was evaluated by calculating the coefficient of concordance (Kappa). The kappa score depended upon the degree of detail in the diagnosis; it was 0.43 for the presence or not of an epithelial abnormality (the General Categorization of the Bethesda system), and rather higher (0.5) for separating low grade from high grade (HSIL or worse) abnormalities or glandular lesions. Agreement was only fair (0.37) when the more detailed Bethesda categories (seven) were used. The reproducibility of cervical cytology evaluations is critical to the success of screening programmes, and in this programme in a moderate-high risk population of women in rural Thailand, we found that agreement between skilled observers, at the level of tests requiring diagnostic follow-up or not, was only moderate. The women in this study are being traced to evaluate the true sensitivity of screening in terms of the lesions found on histology, during a prolonged follow up of 4 or more years.

Experience with a self-administered device for cervical cancer screening by Thai women with different educational backgrounds.

Background: This descriptive study was carried out to test the acceptability of a self-administered device for cervical cancer screening and assess certain risk factors in relation to the cancer in two districts of Khon Kaen province in Northeast Thailand. Methods: A total of 354 women from the villages were selected (including 143 teachers from secondary and primary schools; 24 health officers from the rural health centres, and 37 nurses from the University Hospital, Khon Kaen University). The Kato device was introduced and used by the women, who were then asked to give their opinion on its usage. Results: The Kato device was generally well accepted by the women. However, many of those with a higher educational background were more sceptical towards the device than their counterparts from the villages. Conclusions: A suitable approach to strengthen the control of cervical cancer in the rural areas of Thailand might be to introduce the Kato device as an integral part of primary health care. The introduction of the device should go along with health education on the importance of avoiding infection with the papilloma viruses. This message should be transmitted to both females and males.

A comparison of cytology with Pap smears taken by a gynecologist and with a self-sampling device.

Cervical cancer is the most common cancer in Thai women and as yet screening programmes are minimally effective. The Pap smear is the test accepted to be most appropriate for cervical cancer screening so far. One of the main reasons why women do not come to have Pap smear done is "shyness", which weakens compliance with recommendations to undergo Pap smear with pelvic examination. The self-administered device by the Kato method was established to overcome this problem and the present study was carried out to confirm the adequacy of the specimens obtained with this technique in comparison with specimens collected by gynecologists. Two hundred women were invited to participate in the study voluntarily. Each was allocated to have a Pap smear conducted by a gynecologist and then instructed to produce a self-obtained smear using Kato's device. The cytology results of Pap smears from both methods were compared to test for agreement using Kappa statistics. There was agreement between the adequacy of smears collected by gynecologists and those self-sampled with the percentage agreement of 96.5% and a Kappa score of 0.43 (95% CI 0.33-0.54, P<0.001). There were 8 cases detected as epithelial cell abnormalities from the cervical cells collected by gynecologists and also with the self-administered technique. Good agreement for detection of cellular changes was found with a percentage of 78.0% and the Kappa's score was 0.61 (95% CI 0.46-0.76, P<0.001). The results from this study provide convincing evidence that the self-administered device can be an alternative choice for women who are too shy to undergo pelvic examination or even for those who have limited time to visit health care centers or doctors to have a Pap smear test.

The coverage of cervical cancer screening in Khon Kaen, northeast Thailand.

Cervical cancer is a common cancer in Thai women and one of the only cancers that can be readily cured if early detection is successful. The Pap smear is an accepted as an appropriate means for cervical cancer screening at present. However, there are still some management problems with early detection programmes. Since data showing how many women have been screened by Pap smear are limited in Thailand, the present study was conducted with the aim of determining coverage in a defined population in the sample area, Thakaserm sub- district in Nampong district, Khon Kaen province, Thailand. The investigation was carried out during June-August 2000 to collect information on history of screening for cervical cancer using questionnaires. All women aged 20 and above were asked to answer the set of questionnaires a total of 1199 women responded. There were 66.9% that reported having received a Pap smear test for screening for cervical cancer at least once. However, there were 33.1 % that had never undergone a Pap smear in their life. It is important to find a strategy to increase the coverage of cervical cancer screening programme for this population.