Monsonego Joseph
Institut Alfred Fournier, Paris.
Presse Med. 2007 Jan;36(1 Pt 2):92-111. doi: 10.1016/j.lpm.2006.10.023. Epub 2006 Dec 11.
Worldwide, cervical cancer is diagnosed annually in more than 500,000 women and accounts for 270,000 deaths, making it the second leading cause of cancer in women. In Europe, where many countries have set up screening program, cervical cancer ranks third among cancers in women. In France, cervical cancer is diagnosed in 3400-4500 women each year and kills 1000-1600. Since its introduction, Pap smear screening has transformed cervical cancer from a fatal disease into a rare condition. Despite the considerable success of this cytologic screening, Pap smears have not, as was first hoped, reduced incidence on a large scale. The principal reasons are related to the difficulties in ensuring optimum coverage of the population to be screened and in maximizing women's adherence: the success of screening depends on strict compliance with the calendar from 25 to 65 years of age. In 1/3 of cases, invasive cancers are found in women who undergo regular screening, because Pap smears are insufficiently sensitive. In 5% of cases, cancers are observed in women who were inappropriately managed after an abnormal Pap smear finding. The contribution of the HPV test to primary screening opens up promising perspectives of optimum protection. The test's sensitivity for high-grade lesions exceeds 95% and its negative predictive value exceeds 99%. The HPV test is the only test available for which a negative result provides instantaneous assurance that there is no risk of cervical cancer. The Pap smear alone, with its sensitivity of less than 70%, cannot provide this certainty. European and American guidelines recommend screening strategies based on a combined test using the Pap smear and HPV test after the age of 30 years. The impending availability of prophylactic HPV vaccines, which are expected to provide 70% protection against cervical cancer, will not affect the practice of screening, which must continue.
在全球范围内，每年有超过50万女性被诊断出患有宫颈癌，并有27万人死亡，这使其成为女性癌症的第二大主要病因。在欧洲，许多国家都设立了筛查项目，宫颈癌在女性癌症中排名第三。在法国，每年有3400 - 4500名女性被诊断出患有宫颈癌，其中1000 - 1600人死亡。自从巴氏涂片筛查引入以来，宫颈癌已从一种致命疾病转变为一种罕见疾病。尽管这种细胞学筛查取得了相当大的成功，但巴氏涂片并没有像最初期望的那样大规模降低发病率。主要原因与确保待筛查人群的最佳覆盖率以及最大限度提高女性的依从性方面存在困难有关：筛查的成功取决于严格遵守25至65岁的筛查时间表。在三分之一的病例中，定期接受筛查的女性被发现患有浸润性癌症，因为巴氏涂片的敏感性不足。在5%的病例中，在巴氏涂片检查结果异常后未得到适当处理的女性中观察到癌症。HPV检测用于初次筛查带来了实现最佳保护的有前景的前景。该检测对高级别病变的敏感性超过95%，其阴性预测值超过99%。HPV检测是唯一一种阴性结果能即时保证没有宫颈癌风险的检测。仅巴氏涂片，其敏感性低于70%，无法提供这种确定性。欧美指南建议30岁以后采用巴氏涂片和HPV检测联合的筛查策略。预防性HPV疫苗即将上市，预计可提供70%的宫颈癌预防效果，但这不会影响筛查工作，筛查仍须继续。
