Perspective on cervical cancer: why prevent?

Cervical carcinoma (CC) remains a significant health problem in the United States (U.S.) despite the progressive fall in the mortality rate during the past 60 years. However, CC is still the most common cancer among women worldwide and the leading cancer cause of death in many countries. In the U.S., the current age-adjusted incidence of CC is about 8 per 100,000 population, which compares to 54.6 in Peru and 4.2 in Israel. The lifetime risk for acquiring CC in the U.S. is about 1%, while the lifetime risk in Peru is more than 5 times greater. Recently some industrialized countries have reported a 2-3-fold increase in the death rate from CC among women less than 35 years of age. The primary strategy to reduce the incidence and death rate from CC is screening by cervical cytology. Because of the high incidence of CC precursor lesions, as well as the lack of specifically and sensitivity, CC screening has proven very costly. Nevertheless, in countries or regions where such screening has been repetitive and comprehensive, the mortality rate from CC has been reduced up to 80%, with most cases of CC occurring in non-compliant patients. The decrease in mortality results from detection of invasive cancer at an earlier, and therefore more curable stage, as well as detection and treatment of precursors which prevent the development of invasive carcinoma. Because the strategy involves detection of cancer precursors, the rate of abnormal Pap smears and the number of women requiring medical intervention is many times higher than the CC rate. The age-adjusted incidence of carcinoma in situ is reported to be 3-5-fold that of invasive cervical cancers. The age-adjusted incidence of all dysplasias is unknown, but it is reported that more than half (perhaps up to 90%) of mild and moderate dysplasias regress spontaneously. Considering that there are 15,000 cases of invasive cervical cancer diagnosed in the U.S. annually, cytologic screening involves the diagnosis and treatment of 750,000 or more women each year for precursor lesions. The impact of CC on the patient and society, as well as the role of other strategies for early diagnosis and prevention, will be briefly reviewed.