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Rev Bras Ginecol Obstet. 2014;36(4):182-187
DOI 10.1590/S0100-7203201400040004
To evaluate the impact of training professionals involved in the screening for cervical cancer in Basic Health Units in the city of Goiânia (GO).
This was and intervention study in which the following data contained in the cervical cytopathology test form were examined: the woman's personal data, anamnesis, clinical examination and identification of the professional responsible for the collection. Professional training was evaluated by comparing the forms referring to the period from January 2007 to April 2009, before training, with the forms referring to the period from July 2010 to December 2012, after training. The Pearson χ2 test was used to analyze the results of training, with the 5% level of significance.
After training, there was a significantly increased frequency of recording patient schooling (from 67.2 to 92.6%, p<0.001), telephone number (from 78.9 to 98.7%, p<0.001), cervical inspection (from 86.8 to 96.6%, p<0.001), and signs suggestive of sexually transmitted diseases (from 80.8 to 93.5%, p<0.001). There was a reduction in the frequency of performing the exam within an interval of less than one year (p<0.001) and of one year (p<0.001). There was a reduction in the frequency of Pap smear testing in women under 25 years of age, from 22.0 to 17.9% (p<0.001). There was a significant increase in the proportion of satisfactory samples from 70.4 to 80.2% (p<0.001). A reduction of confounding factors was observed. The desiccation frequency was 2.9% before training and 2.0% after training (p<0.001). There was an increase in the frequency of representation of endocervical cells from 79.5 to 88.5% (p<0.001).
After training, there was a significant improvement in completing the application form, the performance of such tests regarding frequency and the age range recommended by the Ministry of Health, and the adequacy of the sample.
Summary
Rev Bras Ginecol Obstet. 2014;36(4):182-187
DOI 10.1590/S0100-7203201400040004
To evaluate the impact of training professionals involved in the screening for cervical cancer in Basic Health Units in the city of Goiânia (GO).
This was and intervention study in which the following data contained in the cervical cytopathology test form were examined: the woman's personal data, anamnesis, clinical examination and identification of the professional responsible for the collection. Professional training was evaluated by comparing the forms referring to the period from January 2007 to April 2009, before training, with the forms referring to the period from July 2010 to December 2012, after training. The Pearson χ2 test was used to analyze the results of training, with the 5% level of significance.
After training, there was a significantly increased frequency of recording patient schooling (from 67.2 to 92.6%, p<0.001), telephone number (from 78.9 to 98.7%, p<0.001), cervical inspection (from 86.8 to 96.6%, p<0.001), and signs suggestive of sexually transmitted diseases (from 80.8 to 93.5%, p<0.001). There was a reduction in the frequency of performing the exam within an interval of less than one year (p<0.001) and of one year (p<0.001). There was a reduction in the frequency of Pap smear testing in women under 25 years of age, from 22.0 to 17.9% (p<0.001). There was a significant increase in the proportion of satisfactory samples from 70.4 to 80.2% (p<0.001). A reduction of confounding factors was observed. The desiccation frequency was 2.9% before training and 2.0% after training (p<0.001). There was an increase in the frequency of representation of endocervical cells from 79.5 to 88.5% (p<0.001).
After training, there was a significant improvement in completing the application form, the performance of such tests regarding frequency and the age range recommended by the Ministry of Health, and the adequacy of the sample.
Summary
Rev Bras Ginecol Obstet. 2012;34(6):248-253
DOI 10.1590/S0100-72032012000600002
PURPOSE: To verify whether women with atypias of undetermined significance and precursor lesions or invasive cervical outcomes were referred to Medium Complexity Units (MCU) following the guidelines recommended by the Brazilian Ministry of Health. METHODS: Retrospective study based on the cytopathological outcomes of users of the Unified Health System, seen at Basic Health Assistance Units (BHAU) and referred to MCUs in the municipality of Goiânia, state of Goiás, from 2005 to 2006. We assessed 832 records according to the recommendations of the Brazilian Ministry of Health, as established by the Brazilian Nomenclature for Cervical Cytopathologic Outcomes and Recommended Clinical Practice. To check the distribution of variables such as reasons for referral, results of colposcopy and histopathology and clinical procedures we calculated absolute and relative frequencies, mean, minimum and maximum values. RESULTS: We understood 72.7% of the referrals were not in accordance with the recommendations of the Ministry of Health. There were 605 women with test results classified as atypical squamous cells of undetermined significance, possibly non-neoplasms, and squamous intraepithelial lesion of low level which were sent to MCU, and of these 71.8% were submitted to colposcopy, and 64.7% had histopathological examination which results were classified as 31.0% with non-neoplasms and 44.6% as NIC I. Out of 211 women with results classified as more severe squamous lesions, 86.3% were submitted to colposcopy and 68.7% of these had histopathological examinations. CONCLUSIONS: The results of this study revealed high rates of inappropriate referrals to MCU, which required a high percentage of unnecessary procedures. The recommendations of the Ministry of Health were followed by BHAU and the majority of women received counseling/treatment as recommended.
Summary
Rev Bras Ginecol Obstet. 2012;34(6):248-253
DOI 10.1590/S0100-72032012000600002
PURPOSE: To verify whether women with atypias of undetermined significance and precursor lesions or invasive cervical outcomes were referred to Medium Complexity Units (MCU) following the guidelines recommended by the Brazilian Ministry of Health. METHODS: Retrospective study based on the cytopathological outcomes of users of the Unified Health System, seen at Basic Health Assistance Units (BHAU) and referred to MCUs in the municipality of Goiânia, state of Goiás, from 2005 to 2006. We assessed 832 records according to the recommendations of the Brazilian Ministry of Health, as established by the Brazilian Nomenclature for Cervical Cytopathologic Outcomes and Recommended Clinical Practice. To check the distribution of variables such as reasons for referral, results of colposcopy and histopathology and clinical procedures we calculated absolute and relative frequencies, mean, minimum and maximum values. RESULTS: We understood 72.7% of the referrals were not in accordance with the recommendations of the Ministry of Health. There were 605 women with test results classified as atypical squamous cells of undetermined significance, possibly non-neoplasms, and squamous intraepithelial lesion of low level which were sent to MCU, and of these 71.8% were submitted to colposcopy, and 64.7% had histopathological examination which results were classified as 31.0% with non-neoplasms and 44.6% as NIC I. Out of 211 women with results classified as more severe squamous lesions, 86.3% were submitted to colposcopy and 68.7% of these had histopathological examinations. CONCLUSIONS: The results of this study revealed high rates of inappropriate referrals to MCU, which required a high percentage of unnecessary procedures. The recommendations of the Ministry of Health were followed by BHAU and the majority of women received counseling/treatment as recommended.
Summary
Rev Bras Ginecol Obstet. 2014;36(9):398-403
DOI 10.1590/SO100-720320140004996
To evaluate the impact of continued education provided by an external quality control laboratory on the indicators of internal quality control of cytopathology exams.
The internal quality assurance indicators for cytopathology exams from 12 laboratories monitored by the External Quality Control Laboratory were evaluated. Overall, 185,194 exams were included, 98,133 of which referred to the period preceding implementation of a continued education program, while 87,061 referred to the period following this intervention. Data were obtained from the Cervical Cancer Database of the Brazilian National Health Service.
Following implementation of the continued education program, the positivity index (PI) remained within recommended limits in four laboratories. In another four laboratories, the PI progressed from below the limits to within the recommended standards. In one laboratory, the PI remained low, in two laboratories, it remained very low, and in one, it increased from very low to low. The percentage of exams compatible with a high-grade squamous intraepithelial lesion (HSIL) remained within the recommended limits in five laboratories, while in three laboratories it progressed from below the recommended levels to >0.4% of the total number of satisfactory exams, and in four laboratories it remained below the standard limit. Both the percentage of atypical squamous cells of undetermined significance (ASC-US) in relation to abnormal exams, and the ratio between ASC-US and intraepithelial lesions remained within recommended levels in all the laboratories investigated.
An improvement was found in the indicators represented by the positivity index and the percentage of exams compatible with a high-grade squamous intraepithelial lesion, showing that the role played by the external quality control laboratory in providing continued education contributed towards improving laboratory staff skills in detecting cervical cancer precursor lesions.
Summary
Rev Bras Ginecol Obstet. 2014;36(9):398-403
DOI 10.1590/SO100-720320140004996
To evaluate the impact of continued education provided by an external quality control laboratory on the indicators of internal quality control of cytopathology exams.
The internal quality assurance indicators for cytopathology exams from 12 laboratories monitored by the External Quality Control Laboratory were evaluated. Overall, 185,194 exams were included, 98,133 of which referred to the period preceding implementation of a continued education program, while 87,061 referred to the period following this intervention. Data were obtained from the Cervical Cancer Database of the Brazilian National Health Service.
Following implementation of the continued education program, the positivity index (PI) remained within recommended limits in four laboratories. In another four laboratories, the PI progressed from below the limits to within the recommended standards. In one laboratory, the PI remained low, in two laboratories, it remained very low, and in one, it increased from very low to low. The percentage of exams compatible with a high-grade squamous intraepithelial lesion (HSIL) remained within the recommended limits in five laboratories, while in three laboratories it progressed from below the recommended levels to >0.4% of the total number of satisfactory exams, and in four laboratories it remained below the standard limit. Both the percentage of atypical squamous cells of undetermined significance (ASC-US) in relation to abnormal exams, and the ratio between ASC-US and intraepithelial lesions remained within recommended levels in all the laboratories investigated.
An improvement was found in the indicators represented by the positivity index and the percentage of exams compatible with a high-grade squamous intraepithelial lesion, showing that the role played by the external quality control laboratory in providing continued education contributed towards improving laboratory staff skills in detecting cervical cancer precursor lesions.
Summary
Rev Bras Ginecol Obstet. 2007;29(8):402-407
DOI 10.1590/S0100-72032007000800004
PURPOSE: to evaluate the efficiency of the 100% rapid rescreening in the detection of false-negative results and to verify whether the results vary according to the adequacy of the sample and the woman’s age group. METHODS: to evaluate the efficiency of the rapid rescreening, the 5,530 smears classified as negative by the routine screening, after being submitted to the rapid rescreening of 100%, were compared with the rescreening of the smears on the basis of clinical criteria and 10% random rescreening. For statistical analysis, the variables were evaluated descriptively and the c² test and the Cochran-Armitage test were applied to compare results. RESULTS: of the 141 smears identified as suspicious according to the rapid rescreening method, 84 (59.6%) cases were confirmed in the final diagnosis, of which 36 (25.5%) were classified as atypical squamous cells of undetermined significance, five (3.5%) as atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion, 34 (24.1%) as low-grade squamous intraepithelial lesion, six (4.3%) as high-grade squamous intraepithelial lesion, and three (2.1%) as atypical glandular cells. Of the 84 suspect smears confirmed in the final diagnosis, 62 (73.8%) smears were classified as adequate and 22 (26.2%) as adequate but with some limitation, but no significant difference was observed with the woman’s age. CONCLUSIONS: the results of this study show that rapid rescreening is an efficient option for internal quality control for the detection of false-negative cervical smear results. In addition, it should be noted that rapid rescreening performed better when the sample was classified as adequate for analysis; however, it did not vary according to the woman’s age group.
Summary
Rev Bras Ginecol Obstet. 2007;29(8):402-407
DOI 10.1590/S0100-72032007000800004
PURPOSE: to evaluate the efficiency of the 100% rapid rescreening in the detection of false-negative results and to verify whether the results vary according to the adequacy of the sample and the woman’s age group. METHODS: to evaluate the efficiency of the rapid rescreening, the 5,530 smears classified as negative by the routine screening, after being submitted to the rapid rescreening of 100%, were compared with the rescreening of the smears on the basis of clinical criteria and 10% random rescreening. For statistical analysis, the variables were evaluated descriptively and the c² test and the Cochran-Armitage test were applied to compare results. RESULTS: of the 141 smears identified as suspicious according to the rapid rescreening method, 84 (59.6%) cases were confirmed in the final diagnosis, of which 36 (25.5%) were classified as atypical squamous cells of undetermined significance, five (3.5%) as atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion, 34 (24.1%) as low-grade squamous intraepithelial lesion, six (4.3%) as high-grade squamous intraepithelial lesion, and three (2.1%) as atypical glandular cells. Of the 84 suspect smears confirmed in the final diagnosis, 62 (73.8%) smears were classified as adequate and 22 (26.2%) as adequate but with some limitation, but no significant difference was observed with the woman’s age. CONCLUSIONS: the results of this study show that rapid rescreening is an efficient option for internal quality control for the detection of false-negative cervical smear results. In addition, it should be noted that rapid rescreening performed better when the sample was classified as adequate for analysis; however, it did not vary according to the woman’s age group.
Summary
Rev Bras Ginecol Obstet. 2006;28(8):479-485
DOI 10.1590/S0100-72032006000800007
PURPOSE: to evaluate whether factors related to the adequacy of the sample, cell pattern and cytomorphological criteria are associated with false-negative (FN) results of cervical cytopathology during routine examinations. METHODS: this is a case-control study in which the study group included 100 cytopathologic smears with FN results detected during systematic internal quality control consisting of 100% rapid review. For each FN result detected, two smears with a true-positive diagnosis were identified by the same cytotechnician and these constituted the control group, making a total sample size of 300 smears. The variables were established in accordance with the criteria defined for the analysis of sample adequacy, cell pattern and cytomorphological analyzed criteria. The results were evaluated using bivariate analysis and logistic regression with stepwise variable selection criteria expressed in OR (95%). RESULTS: the number of atypical cells, the appearance of nuclear chromatin, and the distribution and presentation of atypical cells in the smear were the variables that showed the greatest risk for FN results with OR of 9.6, 4.2, 4.4, and 3.6, respectively. Inflammatory processes and the presence of blood in the smear were also identified as variables that influence the risk of FN results. CONCLUSIONS: the majority of the factors associated with FN results are dependent on the conditions and techniques of sample collection, since in the majority of cases, the lesion may not be adequately represented in the smear. Confounding factors such as blood and inflammatory processes may also impair analysis. With respect to cytomorphological alterations, thin chromatin strand was the variable that indicated the greatest risk of FN results.
Summary
Rev Bras Ginecol Obstet. 2006;28(8):479-485
DOI 10.1590/S0100-72032006000800007
PURPOSE: to evaluate whether factors related to the adequacy of the sample, cell pattern and cytomorphological criteria are associated with false-negative (FN) results of cervical cytopathology during routine examinations. METHODS: this is a case-control study in which the study group included 100 cytopathologic smears with FN results detected during systematic internal quality control consisting of 100% rapid review. For each FN result detected, two smears with a true-positive diagnosis were identified by the same cytotechnician and these constituted the control group, making a total sample size of 300 smears. The variables were established in accordance with the criteria defined for the analysis of sample adequacy, cell pattern and cytomorphological analyzed criteria. The results were evaluated using bivariate analysis and logistic regression with stepwise variable selection criteria expressed in OR (95%). RESULTS: the number of atypical cells, the appearance of nuclear chromatin, and the distribution and presentation of atypical cells in the smear were the variables that showed the greatest risk for FN results with OR of 9.6, 4.2, 4.4, and 3.6, respectively. Inflammatory processes and the presence of blood in the smear were also identified as variables that influence the risk of FN results. CONCLUSIONS: the majority of the factors associated with FN results are dependent on the conditions and techniques of sample collection, since in the majority of cases, the lesion may not be adequately represented in the smear. Confounding factors such as blood and inflammatory processes may also impair analysis. With respect to cytomorphological alterations, thin chromatin strand was the variable that indicated the greatest risk of FN results.
Summary
Rev Bras Ginecol Obstet. 2008;30(11):556-560
DOI 10.1590/S0100-72032008001100005
PURPOSE: to evaluate whether the sample adequacy influences the detection of precursor cervical cancer lesions. METHODS: a transversal study from January 2004 to December 2005. A number of 10,951 results of cervical cytotopathological exams from users of the National Health System (Sistema Único de Saúde, SUS) in Goiânia, Goiás , Brazil, was studied. These women had spontaneously looked for the services from the Family Health Program or from the Basic Units of Health. Samples were collected by medical doctors and nurses, through the conventional technique to detect cervical cancer. The analyzed smears were classified by the Bethesda System, the sample adequacy being defined along the routine screening and categorized as: satisfactory, satisfactory but presenting factors that might partially jeopardize the analysis, and unsatisfactory. Results were stored in the Epi-Info 3.3.2 program. The χ2 test was used to compare altered results with the adequacy of the samples from cytopathological smears. Differences with probability of rejection of the null hypothesis lower than 5% (p<0.05) were considered as significant. RESULTS: From 10,951 smears, 51.1% were classified as having satisfactory adequacy for analysis, 46.6% as satisfactory, but presenting some limiting factors, and 2.3%, as unsatisfactory. The main factors which have partially jeopardized the analysis were: lack of endocervical cells (52.2%), dried smears (22.8%), purulence (14.9%), or smears with some thick areas (9.5%). There was a higher rate of altered smears when the sample had been classified as satisfactory for analysis and with representation of endocervical cells ASC-US (2.3%), ASC-H (0.6%), LSIL (3.2%), HSIL (1.7%) and 0.3% of AGC. Differences were significant when p=0.001. The rate of low and high grade lesions was higher when the smears were satisfactory for analysis. CONCLUSIONS: the rate of precursor uterine cervix cancer lesions varies according to the sample adequacy, and the main adequacy limitations of the sample are mainly related to the collection condition.
Summary
Rev Bras Ginecol Obstet. 2008;30(11):556-560
DOI 10.1590/S0100-72032008001100005
PURPOSE: to evaluate whether the sample adequacy influences the detection of precursor cervical cancer lesions. METHODS: a transversal study from January 2004 to December 2005. A number of 10,951 results of cervical cytotopathological exams from users of the National Health System (Sistema Único de Saúde, SUS) in Goiânia, Goiás , Brazil, was studied. These women had spontaneously looked for the services from the Family Health Program or from the Basic Units of Health. Samples were collected by medical doctors and nurses, through the conventional technique to detect cervical cancer. The analyzed smears were classified by the Bethesda System, the sample adequacy being defined along the routine screening and categorized as: satisfactory, satisfactory but presenting factors that might partially jeopardize the analysis, and unsatisfactory. Results were stored in the Epi-Info 3.3.2 program. The χ2 test was used to compare altered results with the adequacy of the samples from cytopathological smears. Differences with probability of rejection of the null hypothesis lower than 5% (p<0.05) were considered as significant. RESULTS: From 10,951 smears, 51.1% were classified as having satisfactory adequacy for analysis, 46.6% as satisfactory, but presenting some limiting factors, and 2.3%, as unsatisfactory. The main factors which have partially jeopardized the analysis were: lack of endocervical cells (52.2%), dried smears (22.8%), purulence (14.9%), or smears with some thick areas (9.5%). There was a higher rate of altered smears when the sample had been classified as satisfactory for analysis and with representation of endocervical cells ASC-US (2.3%), ASC-H (0.6%), LSIL (3.2%), HSIL (1.7%) and 0.3% of AGC. Differences were significant when p=0.001. The rate of low and high grade lesions was higher when the smears were satisfactory for analysis. CONCLUSIONS: the rate of precursor uterine cervix cancer lesions varies according to the sample adequacy, and the main adequacy limitations of the sample are mainly related to the collection condition.
Summary
Rev Bras Ginecol Obstet. 2016;38(2):65-70
The objective of this study is to assess the performance of cytopathology laboratories providing services to the Brazilian Unified Health System (Sistema Único de Saúde - SUS) in the State of Minas Gerais, Brazil.
This descriptive study uses data obtained from the Cervical Cancer Information System from January to December 2012. Three quality indicators were analyzed to assess the quality of cervical cytopathology tests: positivity index, percentage of atypical squamous cells (ASCs) in abnormal tests, and percentage of tests compatiblewith high-grade squamous intraepithelial lesions (HSILs). Laboratories were classified according to their production scale in tests per year≤5,000; from 5,001 to 10,000; from 10,001 to 15,000; and 15,001. Based on the collection of variables and the classification of laboratories according to production scale, we created and analyzed a database using Microsoft Office Excel 97-2003.
In the Brazilian state of Minas Gerais, 146 laboratories provided services to the SUS in 2012 by performing a total of 1,277,018 cervical cytopathology tests. Half of these laboratories had production scales≤5,000 tests/year and accounted for 13.1% of all tests performed in the entire state; in turn, 13.7% of these laboratories presented production scales of > 15,001 tests/year and accounted for 49.2% of the total of tests performed in the entire state. The positivity indexes of most laboratories providing services to the SUS in 2012, regardless of production scale, were below or well below recommended limits. Of the 20 laboratories that performed more than 15,001 tests per year, only three presented percentages of tests compatible with HSILs above the lower limit recommended by the Brazilian Ministry of Health.
The majority of laboratories providing services to the SUS in Minas Gerais presented quality indicators outside the range recommended by the Brazilian Ministry of Health.
Summary
Rev Bras Ginecol Obstet. 2016;38(2):65-70
The objective of this study is to assess the performance of cytopathology laboratories providing services to the Brazilian Unified Health System (Sistema Único de Saúde - SUS) in the State of Minas Gerais, Brazil.
This descriptive study uses data obtained from the Cervical Cancer Information System from January to December 2012. Three quality indicators were analyzed to assess the quality of cervical cytopathology tests: positivity index, percentage of atypical squamous cells (ASCs) in abnormal tests, and percentage of tests compatiblewith high-grade squamous intraepithelial lesions (HSILs). Laboratories were classified according to their production scale in tests per year≤5,000; from 5,001 to 10,000; from 10,001 to 15,000; and 15,001. Based on the collection of variables and the classification of laboratories according to production scale, we created and analyzed a database using Microsoft Office Excel 97-2003.
In the Brazilian state of Minas Gerais, 146 laboratories provided services to the SUS in 2012 by performing a total of 1,277,018 cervical cytopathology tests. Half of these laboratories had production scales≤5,000 tests/year and accounted for 13.1% of all tests performed in the entire state; in turn, 13.7% of these laboratories presented production scales of > 15,001 tests/year and accounted for 49.2% of the total of tests performed in the entire state. The positivity indexes of most laboratories providing services to the SUS in 2012, regardless of production scale, were below or well below recommended limits. Of the 20 laboratories that performed more than 15,001 tests per year, only three presented percentages of tests compatible with HSILs above the lower limit recommended by the Brazilian Ministry of Health.
The majority of laboratories providing services to the SUS in Minas Gerais presented quality indicators outside the range recommended by the Brazilian Ministry of Health.