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Cervical cancer screening
marry-ins after 1952. The lifetime use of OCs was 5 1% and was similar for both groups. After analysis, ever use of an OC was found to have a relative risk of 1.4 for breast cancer when compared with a never user. Duration of use appeared to make no difference. However, when granddaughters and nieces and marry-ins were evaluated separately there was no increased relative risk of breast cancer. Among sisters and daughters only, the relative risk was then recalculated at 3.3 for ever users of OCs. The risk in these women was greatest in those who used an OC before 1975. They concluded that ever use of an OC in earlier formulations in patients who have a firstdegree relative with breast cancer increases the patient’s risk of developing breast cancer. (Level 11-3)
can have on subsequent generations; despite careful statistical analysis, however, the data are still not conclusive.
Cervical Cancer Screening Denny L, Kuhn L, Pollack A, Wainwright H, Wright TC Jr. Evaluation of alternative methods of cervical cancer screening for resource-poor settings. Cancer 2000;89:82633.
Synopsis: Evaluation of the cervix in a resource-poor setting where the population is at high risk for cervical carcinoma was the basis of this study by the investigators from South Africa. There were 2944 women aged 35-65 in the study population from January 1996 to September 1997. These patients had no history of prior screening for cervical cancer. They were then screened with a Papanicolaou smear, human papillomavirus DNA assay, direct visual inspection (DVI) after application of 5% acetic acid solution, and cervicography. Positive lesions were referred for colposcopy and cervical biopsy. Abnormalities were identified in 29% of the patients (842/2944) in one or more of these four tests. They found I2 cases of invasive carcinoma, 74 cases of high-grade squamous intraepithelial lesions (SIL), and 95 cases of lowgrade SIL. About 78% of women whose Papanicolaou smears identified higher-grade disease (SIL or invasive cancer) had the diagnosis proved on biopsy. DNA analysis and DVI identified similar numbers of high grade SIL or invasive cancer. However, these two methods identified more women as positive who were without evidence of the disease, thus giving low specificity to these tests. (Level 11-2)
. . .
Commentary: This study has attempted to evaluate a 5O-year histq of families with breast cancer and then correlate their female relatives and the use of OCs. This study was ambitious and the follow-up was excellent. However, any study of this type is difficult to analyze in an uncontrolled environment because a time frame of this magnitude allows multiple uncontrolled variables to intervene. The authors recognize that the high hormone levels of the earlier OCs may have played a role. This finding had been shown in other studies. Any telephone-based interview that relies on recall data is subject to the interviewees’ biases, knowledge, and reliability. Even in large studies such as this, these inaccuracies can result in wrong data. These authors have tried to correct where possible for any confounding variable. What they cannot correct for is the evolving understanding of risk factors for breast cancer that may or may not have been present in these index families. A significant component that is unknown is the genetic background of these patients. There were no studies of BRCAl or BRCA.2 genes at that time and subsequent generations could have lost the carrier status. Diet and dietary awareness of risk factors have changed, as has the role of smoking. This study has given us some insight into the role that OCs in women
. . .
Commentary: Cervical carcinoma is still a major problem in developing countries. Because of limited resources, mass screening such as occurs in the United States and western Europe is nonexistent. A number of studies have shown that DVI may be a useful adjunct. This study has shown similar results. The DVI was similar
to the Papanicolaou smear in identification but neither was >80% effective. The difficulty with the Papanicolaou smear technology in these countries is the lack of trained technicians or of the resources to acquire or train the necessary personnel for screening. Direct visual inspection appears to be developing as an acceptable alternative to no screening. Direct visual inspection has been used by health technicians in some studies and has had similar results to this study. This may be one approach to the problem and although DVI will not identify all cases in these low resource areas, it will certainly be better than what now exists and is a reasonable alternative based on the economic realities.
OC Use and Glucose Metabolism in the United States Troisi RJ, Cowie CC, Harris MI. Oral contraceptive use and glucose metabolism in a national sample of women in the United States. Am J Obstet Gynecol 2000;183:
389-95. Synopsis: Determining whether women taking oral contraceptives (OCs) have elevated measures of glucose metabolism was the objective of this study. They used cross sectional data from the third National Health and Nutrition Examination Survey, which was conducted from 1988 through 1994 in 89 randomly selected locations. There were 5482 women aged 17-44 in the study population who were interviewed at home. After evaluation of the information and exclusion of variables, there remained 70 women with diabetes and 4 120 without. Of the women without diabetes, 1070 never used OCs, 803 were current users and 2247 were past users. They assessed four measures of glucose metabolism: hemoglobin A,, (HbA,,), fasting glucose, insulin, and C-peptide levels. Most women were using low-dose estrogen either as a triphasic or monophasic preparation. Current users had no elevated levels for any of the four measures. The levels were not related to duration of use, age at first use, or formation type. Thus, they
02001 by theAmertcanCollege ofObstetricians and Gynecologists Published by ElsevwScience Inc 10656862!011$6.00
January/February
200 1
l
ACOG
CLINICAL
REVIEW
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7
can have on subsequent generations; despite careful statistical analysis, however, the data are still not conclusive.
Cervical Cancer Screening Denny L, Kuhn L, Pollack A, Wainwright H, Wright TC Jr. Evaluation of alternative methods of cervical cancer screening for resource-poor settings. Cancer 2000;89:82633.
Synopsis: Evaluation of the cervix in a resource-poor setting where the population is at high risk for cervical carcinoma was the basis of this study by the investigators from South Africa. There were 2944 women aged 35-65 in the study population from January 1996 to September 1997. These patients had no history of prior screening for cervical cancer. They were then screened with a Papanicolaou smear, human papillomavirus DNA assay, direct visual inspection (DVI) after application of 5% acetic acid solution, and cervicography. Positive lesions were referred for colposcopy and cervical biopsy. Abnormalities were identified in 29% of the patients (842/2944) in one or more of these four tests. They found I2 cases of invasive carcinoma, 74 cases of high-grade squamous intraepithelial lesions (SIL), and 95 cases of lowgrade SIL. About 78% of women whose Papanicolaou smears identified higher-grade disease (SIL or invasive cancer) had the diagnosis proved on biopsy. DNA analysis and DVI identified similar numbers of high grade SIL or invasive cancer. However, these two methods identified more women as positive who were without evidence of the disease, thus giving low specificity to these tests. (Level 11-2)
. . .
Commentary: This study has attempted to evaluate a 5O-year histq of families with breast cancer and then correlate their female relatives and the use of OCs. This study was ambitious and the follow-up was excellent. However, any study of this type is difficult to analyze in an uncontrolled environment because a time frame of this magnitude allows multiple uncontrolled variables to intervene. The authors recognize that the high hormone levels of the earlier OCs may have played a role. This finding had been shown in other studies. Any telephone-based interview that relies on recall data is subject to the interviewees’ biases, knowledge, and reliability. Even in large studies such as this, these inaccuracies can result in wrong data. These authors have tried to correct where possible for any confounding variable. What they cannot correct for is the evolving understanding of risk factors for breast cancer that may or may not have been present in these index families. A significant component that is unknown is the genetic background of these patients. There were no studies of BRCAl or BRCA.2 genes at that time and subsequent generations could have lost the carrier status. Diet and dietary awareness of risk factors have changed, as has the role of smoking. This study has given us some insight into the role that OCs in women
. . .
Commentary: Cervical carcinoma is still a major problem in developing countries. Because of limited resources, mass screening such as occurs in the United States and western Europe is nonexistent. A number of studies have shown that DVI may be a useful adjunct. This study has shown similar results. The DVI was similar
to the Papanicolaou smear in identification but neither was >80% effective. The difficulty with the Papanicolaou smear technology in these countries is the lack of trained technicians or of the resources to acquire or train the necessary personnel for screening. Direct visual inspection appears to be developing as an acceptable alternative to no screening. Direct visual inspection has been used by health technicians in some studies and has had similar results to this study. This may be one approach to the problem and although DVI will not identify all cases in these low resource areas, it will certainly be better than what now exists and is a reasonable alternative based on the economic realities.
OC Use and Glucose Metabolism in the United States Troisi RJ, Cowie CC, Harris MI. Oral contraceptive use and glucose metabolism in a national sample of women in the United States. Am J Obstet Gynecol 2000;183:
389-95. Synopsis: Determining whether women taking oral contraceptives (OCs) have elevated measures of glucose metabolism was the objective of this study. They used cross sectional data from the third National Health and Nutrition Examination Survey, which was conducted from 1988 through 1994 in 89 randomly selected locations. There were 5482 women aged 17-44 in the study population who were interviewed at home. After evaluation of the information and exclusion of variables, there remained 70 women with diabetes and 4 120 without. Of the women without diabetes, 1070 never used OCs, 803 were current users and 2247 were past users. They assessed four measures of glucose metabolism: hemoglobin A,, (HbA,,), fasting glucose, insulin, and C-peptide levels. Most women were using low-dose estrogen either as a triphasic or monophasic preparation. Current users had no elevated levels for any of the four measures. The levels were not related to duration of use, age at first use, or formation type. Thus, they
02001 by theAmertcanCollege ofObstetricians and Gynecologists Published by ElsevwScience Inc 10656862!011$6.00
January/February
200 1
l
ACOG
CLINICAL
REVIEW
l
7