Is a once‐in‐a‐lifetime pap smear the best option for low‐resourced settings?

Dear Sir, Cervical cancer mortality has not decreased in developing countries in spite of the availability of screening with conventional cytology for nearly 40 years. Much of the research seeking solutions to this increasing disease burden has focused on coverage of screening and accuracy of screening tests per se. The World Health Organization (WHO) has long advocated for cytology-based organized screening programs. Countries have adopted plans for repeated screening based on successful models in industrialized countries.1 More recently, owing to the lack of success, the WHO recommends screening at least once in a lifetime at ages 35–40 in low-resourced countries.2 This being the only opportunity a woman would have for the detection of cervical intraepithelial neoplasia or early detection of cervical cancer, the sensitivity of the test must be high, and most importantly follow-up of women screened positive must be assured. In fact, one of the reasons for the success of screening programs in industrialized countries has been the availability and accessibility of services for diagnostic workup and treatment. Follow-up has not been systematically addressed in developing countries. As part of a larger implementation project, the Pan American Health Organization, which is also the Regional Office of WHO for the Americas, conducted two evaluations of follow-up for women screened positive in clinics serving lowresource settings in Peru and El Salvador. The objective of the assessments was to evaluate whether women screened positive with Pap smears were provided diagnostic and treatment services. In local laboratories of two low-resource areas, cytology reports were reviewed to ascertain the number of women with an abnormal smear during a period preceding the review date by at least 6 months. Information on diagnosis, treatment and disease status was obtained by systematically reviewing medical records from public hospitals and clinics, pathology laboratory registries and death certificates. If no records were found, we visited women at home and used a structured questionnaire to ascertain diagnostic and treatment procedures. Women who had not had any treatment were offered rescreening, diagnosis and treatment at no cost. In the province of San Martin in the Peruvian Amazonia during the period of January 1999 through April 2000, 243 women had a positive smear. One woman was excluded because it had a previous hysterectomy and 9 other lived more than 1 day’s travel from the health center so it was not possible to obtain information. In total, 197 (85.1%) of women who screened positive were found.3 In Chalatenango, El Salvador, 124 women were reported with a positive smear from January through December 2000, and 109 (87.9%) women were found. The proportion of women for whom diagnostic workup was properly documented was very low: 40.8% and 58.1% in Peru and El Salvador, respectively. There were 46 women in Peru and 30 women in El Salvador in whom a positive diagnosis was made, of whom 35 and 26, respectively, completed treatment. Overall, 65% of women who screened positive in Peru and 45% in El Salvador were lost to follow-up or could not be accounted for. These results indicate the low levels of follow-up among women screening positive in these 2 settings; the majority of women remained undiagnosed. Those not found could have sought diagnosis elsewhere. However, in the case of Peru, other diagnostic and treatment services are a long distance away and only women with economic means would have access. In El Salvador, records from the area and in the major hospitals in the capital city were reviewed, but women could have used different names or migrated to other areas. This situation also applies to the poor health record/information system in this country, which could be a barrier toward an organized program.4 Currently, information systems in these 2 countries collect data on health care activities to serve administrative purposes, but are not designed to follow up patients or evaluate health outcomes. A limitation of these rapid assessments is that it cannot provide information on why women did not have diagnostic workup, which would be necessary to take corrective action. In a recent review on this topic, intervention studies to improve follow-up are classified into cognitive, behavioral and sociological.5 Cognitive studies are those that intend to increase knowledge. The authors assign pamphlets and other materials as well as counseling to this category. Behavioral interventions are those that stimulate women to seek care, such as telephone and mail reminders. Sociological interventions include those that use peers to increase follow-up. Overall, cognitive interventions are most successful. Marcus and Crane6 report that in studies in the United States, economic incentives such as subsidies to transportation and vouchers increase follow-up among women from low socioeconomic status, confirming the difficulties these women face when multiple visits are required.