Cervical cancer screening by cytology and the burden of epithelial abnormalities in low resource settings: a tertiary-center 42-year study | BMC Women’s Health

Key results

By analyzing routinely collected healthcare data from 95,120 satisfactory cervical smear records in the ECDU, this study reported trends in screening uptake and in the observed epithelial abnormalities. A notable increase in the number of annually screened women occurred from 1981 to 1992, after which the number of screened women declined. Women who engaged in sexual intercourse at a young age and who made the conscious decision to undergo routine cytological screening exhibited a greater probability of presenting with epithelial abnormalities. Furthermore, these abnormalities were more prevalent among women who underwent the screening process at a relatively advanced age than among their counterparts. The most common epithelial abnormality was LSILs. The yearly number of cervical screenings by cytology was positively associated with LSIL and negatively associated with invasive lesions.

The discrepancy between the recommended cervical cancer screening guidelines and actual clinical practice was identified in a recent systematic review. Only six of 11 countries across North America, Europe, and the Asia–Pacific region have implemented comprehensive population-based screening programs [11]. This observation highlights a potential gap between policy recommendations and real-world implementation of cervical cancer prevention strategies.

Current consensus does not recommend the initiation of cervical cancer screening before the age of 21 years in immunocompetent females due to the very low rate of cervical cancer among women aged 20 to 24 years (0.8 per 100,000) [12]. In Egypt, there is a social tendency for early marriage, and the results of this study revealed that epithelial abnormalities are associated with earlier sexual activity. This might have implications for practice.

This study revealed a 5.44% prevalence of epithelial abnormalities in cervical smears. This finding aligns with reports from other Arab countries, such as Saudi Arabia (4.27%) [13], Jordan (3.8%) [14], the United Arab Emirates (3.3%) [15], and Kuwait (4.4%) [16]. This similarity might be related to shared cultural and religious factors. This prevalence in our study is much lower than that reported in sub-Saharan Africa, as reported in studies from southwestern Nigeria (34.6%) [17] and Northwest Ethiopia (14.1%) [18]. Coexisting HIV infection in these regions is a potential explanation for the higher rates.

In the current study, epithelial abnormalities were significantly more common in women who underwent routine check-ups than in symptomatic women. Other reports have not found such a significant difference [13]. This finding can provide support to the cervical cancer control efforts by providing evidence on the benefit of routine screening rather than only when symptoms arise.

In an age-stratified analysis of the distribution of cytological abnormalities, we found that women older than 60 had the highest prevalence of epithelial abnormalities, possibly due to the limited organized screening programs in Egypt in younger women with accumulation of epithelial abnormalities over time.

Our results indicate that women with ASC were significantly older than those with LSIL and younger than those with HSIL and glandular cells. Patients with LSILs and AGUS were significantly younger than patients with malignant squamous cell carcinoma, HSILs or adenocarcinoma. This was consistent with the findings of previously published results showing that the incidence of ASC, LSIL, and HSIL peaked in the 30–39-year age group, while the incidence of AGUS peaked among individuals aged 40–49 years. The incidence of malignant lesions further increased after the age of 50 years. The mean ages at diagnosis for patients with LSILs and HSILs were 34.7 and 37.7 years, respectively, while patients with malignant lesions presented with a mean age at diagnosis of 51.8 years [19]. This might have implications for screening practice [20].

Over a 42-year period, the number of screened women has decreased. This would explain the decrease in the number of SIL abnormalities from 6.9% to 4.3% for LSILs and from 1.2% to 0.13% for HSILs. This is because screening services in ECDUs currently operate on an opportunistic basis rather than through a structured, population-based approach.

The effectiveness of structured, population-based preventive strategies in reducing the incidence rates of preinvasive and invasive lesions of the cervix cannot be overstated [21,22,23,24]. However, in the vast majority of low- and middle-income countries (LMICs), including Egypt, researchers have identified a diverse array of obstacles to the process of screening [25]. LMICs need prompt and immediate execution of unambiguous regulations, which should be fortified by the ability of the healthcare system to put these regulations into action. We need widespread advocacy within the community and the dissemination of information, alongside the strengthening of policies that promote the well-being of women and ensure gender equality.

Strengths and limitations

Overall, a four-decade study of cervical screening practice in a low resource setting, offers a wealth of information that can significantly contribute to the understanding and improvement of cervical cancer prevention and control. The extended timeframe allows for the collection of comprehensive data providing insights into trends and changes in cervical screening practices. Understanding how cervical screening practices have evolved over four decades can highlight the impact of policy changes and public health initiatives on screening rates. Highly competent pathologists assessed and confirmed cytologic findings, reducing the chances of incorrect classification of screening results. The results obtained in this study, when interpreted in the context of clinical practice, reveals the actual practice in the largest facility in a country of lower middle income and shows the urgent need to adopt a structured screening program and to incporporate state of the art tools for the diagnosis and management [26, 27]. The extensive dataset collected can serve as a valuable resource for future research, allowing for more detailed analyses and the exploration of new research questions.

Limitations of this work includes missing data especially in certain demographic characteristics of women. This might reflect sensitive data in a conservative community or the lack of rigor or inconsistencies when collecting routine data. All demographic data were self-reported by women, which is prone to recall bias. The process of screening for cervical cancer is characterized by opportunistic practices rather than organized efforts. This implies that the subset of women who undergo screening differs from those who do not, as the former group has successfully surmounted various obstacles, such as financial constraints, social factors, cultural influences, and geographic limitations, to avail themselves of screening services. There is also a lack of information relating to the source of referral (e.g., self-referred or provider referred) for screening. The change in terminology used over time may have some implications for the assigned category of abnormality observed. The study lacks the findings on repeated smears for abnormal cytology.

HPV testing became a state of the art in the screening and management [26, 28]. However, the current study did not examine how changes in the healthcare system, such as the introduction of new technologies (e.g., HPV testing), have affected cervical screening practices because of the lack of affordable and accessible and HPV testing nationwide.

This four-decade longitudinal study could have highlighted the role of preventive measures, such as the HPV vaccine, in reducing the incidence of cervical cancer. Unfortunately, the vaccination coverage is unknown and there is no national vaccination program.