Talk:Cervical cancer/Archive 1

History Section provably inaccurate

207.118.25.169 21:47, 19 February 2007 (UTC)"It has since been demonstrated that HPV is implicated in all cervical cancers." Do I need to explain the folly here? First of all, a link has only been found in 90%, not 100% of all cases. Second of all, the use of such words as "all" and "every" have no place in medical and scientific reference. Science, since its early inception in prehistoric stellar cartography, has always been about telling us what isn't, not what is. Use of such absolute statements dilute science as a whole.

On MSN Health website:

Correction, 2/23/2007: This article originally stated that "all women who develop cervical cancer have had a human papilloma virus (HPV) infection." According to the U.S. National Institutes of Health, HPV infection is the primary risk factor for cervical cancer, but other risk factors include a high number of full-term pregnancies, use of oral contraceptives, and smoking.

Needs work

This entry needs a lot of work. It has been filled by the pro-circumcision Wikipedians, but it needs a lot more work. I am not a gynecologist...

• Other clinical signs and symptoms
• Diagnosis: appearance on colposcopy and biopsy
• Pathophysiological mechanisms
• FIGO classification
• When conisation, when radical hysterectomy?
• 5-year survival for different types.

I have reworked the references. I could not find any better article to quote about the smegma-HPV link, but an anonymous article in Chinese is a very poor source, even if it was indexed for Medline. I removed the reference to the Japanese study at the end. No context was provided, and it sounds too technical for Wikipedia. JFW | T@lk 21:59, 25 Nov 2004 (UTC)

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An anonymous user desperate to disprove the smegma-HPV link tried to insert a number of (fairly ancient) references to back this up. While this is laudable, the same anon disrupted formatting of the extant links to conform with the layout of his own website.

It is sickening that this article has (like many others) been drawn into the dreadful pro/anti-circumcision debate. More than a month ago I requested expansion above, but all these morons (on both sides) seem to care about is whether having "the snip" is preventative. Can we please move on, guys, and focus on the post-facto information in this article that is still sorely lacking. JFW | T@lk 13:08, 2 Jan 2005 (UTC)

Just a final moan: the Castellsague reference is pretty convincing re. circumcision as a preventative measure. Society has to choose whether to take on circumcising all males or to live with the consequences. This is a common tradeoff commonly faced in epidemiology. The debate has just politicised beyond reason. JFW | T@lk 13:12, 2 Jan 2005 (UTC)

Castellsaque may be convincing to you, but it is not convincing to everyone. Even if circumcision does reduce the HPV infection, it will not be necessary, once vaccine becomes available.

Robert Blair 12:56, 11 Feb 2005 (UTC)

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• Noted. I wonder who will be able to run a check on the IP to see if this is an alias of one of our regular anti-circumcision POV pushers? - Robert the Bruce 17:03, 2 Jan 2005 (UTC)

I'm not sure if that's quite necessary. One POV pusher may leave and another one will reappear. Unfortunately, User:Skellam has left Wikipedia - he knew quite a bit of gynaecology... JFW | T@lk 11:58, 3 Jan 2005 (UTC)

Robert and Jake

The Castellsaque reference actually is not at all convincing when one views the criticism of the article, especially since Castellsaque's own work conflicts with the findings.

This article needed revision and editing. I have just done that.

Robert Blair 12:38, 8 Feb 2005 (UTC)

Your criticism of Castellsague can stay, but I've edited your changes to remove the appalling POV pushing, and added links to a small fraction of the other studies to address this issue. Please read WP:NPOV - Jakew 12:53, 8 Feb 2005 (UTC)

Dear fellows, I have worked hard on this article to arrive at balanced content and formatting. Your roughshod pro- & anti-circumcision activity disrupts its format. Please do not edit war over here. I will censor both of your POVs; you can fight this battle on medical analysis of circumcision. The bottom line is: HPV is a major cause of cervical carcinoma, and many researchers maintain that HPV infection rate increases in multiple partners and is known to be lower in populations with a high circumcision rate. WHY ARE YOU WASTING YOUR TIME HERE! This is an encyclopedia. It is sufficient to point out that a debate exists, with maximum 2 references of vital interest. JFW | T@lk 13:04, 8 Feb 2005 (UTC)

Removal of relevant material?

I notice that the Heins study "The possible role of smegma in carcinoma of the cervix." has been removed from this article. The onus is surely upon the person who has deleted it to explain and justify the action. I await the explanation eagerly. - Robert the Bruce 03:05, 10 Feb 2005 (UTC)

It was me. If all the evidence for the role of smegma is one 1980s Chinese study and some ancient reference from the 195os, surely the hypothesis has received little attention and is not worth mentioning in a general encyclopedia. Robert, my above rant also applies to you: pro- and anti-circumcision editors will face my wrath if you use this article as a battleground. JFW | T@lk 07:03, 10 Feb 2005 (UTC)

Wolffie, I don't think that is a particularly intelligent position to take. You need to accept that there is a need for a sub-section to deal with this smegma business. I think it would be tantamount to a wikicrime if you continue to delete relevant information just because a group of headbangers take exception. If it is supposedly "controversial" then learn to live with it and deal with it. - Robert the Bruce 16:31, 10 Feb 2005 (UTC)

There were actually several studies in the '50s and '60s that together established smegma as mildly carcinogenic. Other authors were Plaut, Kohn-Speyer, and Reddy. The logical explanation for the lack of recent studies is the fact that there is no point proving that which is already known. - Jakew 15:02, 10 Feb 2005 (UTC)

Smegma is a natural product of the human body. The assertion that it can be carcinogenic is absurd. This dates back to the early 1950s when the true cause was unknown. Removing it from the article was proper.

I have further removed the emphasis on circumcision from this article.

Robert Blair 15:49, 10 Feb 2005 (UTC)

I'm sorry that you find scientific evidence "absurd". Perhaps you find it equally "absurd" that sunlight, in excess, can cause skin cancer. It would seem strange given that we've only been wearing clothes for a few thousand years, but the explanation is the same: it has only been in recent times that the typical human lifespan has been long enough for serious illnesses to have a chance to develop.

Taking about the "true cause" being unknown is a smokescreen: these experiments used careful controls to investigate whether or not smegma is carcinogenic. The simple fact is that it is. Sorry that you don't like it, but it doesn't change the facts. Do you dislike gravity? Too bad: it's still there.

I'll review your changes and make appropriate corrections. - 16:05, 10 Feb 2005 (UTC)

Robert the Bruce: I do not appreciate being called "Wolffie". Guys: I take issue with linking to the CIRP "fulltext" articles. These do not state that rights were granted by The Lancet to reproduce them online.

I must again state that if you want certain changes to happen in this article, you will have to discuss them here first. I am in the pleasant position of disagreeing with all your POVs. While this does not make me impartial, it certainly stops the silly bias from both sides constantly finding its way into the article. JFW | T@lk 21:40, 10 Feb 2005 (UTC)

• JFW, it seems I need to state my position again. But first, pray explain why you believe you have a divine right to take over and "moderate" edits to this article? Secondly, as stated before, there is clearly some controversy attached to this article which should be dealt with. If you are not up to the task (in your self appointed role as owner of this article) to work towards the truth being presented then pass on it and move on and leave it to someone else. - Robert the Bruce 06:44, 11 Feb 2005 (UTC)

You sound unnecessarily patronising. I am up to the task of moderating this article. If you'd read the WikiEN discussion list a bit closer, there is ample support for admin moderation of articles that fall prey to POV-pushing. I'm not sure if I want your version of the truth represented, so I will keep this article firmly in my evil grip until your arbitration case has been decided. JFW | T@lk 07:23, 11 Feb 2005 (UTC)

• I am questioning your actions. I am commenting that you appear to be spiralling out of control. I am stating that where controversy exists it should be faced full square and dealt with and not have little tin gods censuring the article into something vanilla and banal. You have overstepped the mark; you are out of control ... for heavens sake stop it! - Robert the Bruce 12:40, 11 Feb 2005 (UTC)

I am not spiralling out of control; your remarks are, though. The controversy vis a vis cervical cancer is small; you should move your attention to medical analysis of circumcision, instead of wasting your time here. Frankly, all editors have now accused me of censorship, yet I made the largest contribution overall this week, followed closely by Brim. You, Robert II and Jake are just ***** things up. For heaven's sake, all of you, leave this article alone! JFW | T@lk 19:58, 12 Feb 2005 (UTC)

Oh, and the "controversy" you insist on is covered in the article (see /* Pathophysiology */). JFW | T@lk

Robert Blair de-POVs

I have removed circumcision POV pushing. Robert Blair 12:24, 11 Feb 2005 (UTC)

• I am sure you have Robert ... and no doubt replaced it with some anti-circumcision POV pushing stuff. Nice work there Robert. - Robert the Bruce 12:42, 11 Feb 2005 (UTC)

RtB: This kind of sarcastic remark has contributed greatly to your difficulties. What does it take for you to learn? Now, buzz off. Robert Blair 14:40, 12 Feb 2005 (UTC)

• Is there any doubt that you are a rampant POV pusher? LoL who do you think you are fooling? - Robert the Bruce 14:47, 12 Feb 2005 (UTC)

I am a children's advocate. Now, buzz off. Robert Blair 20:42, 13 Feb 2005 (UTC)

Does no one else see the ridiculous irony of your entire debate? This is an article about cervical cancer that has been written, edited, and argued about by men. And you have exerted frightening amounts of effort in a debate on head cheese and the configuration of a penis. Any medical relevance has been erased by blind bias and long left by the wayside in this forum. All that remains is some vague entertainment value. TheLegion677 (talk) 14:37, 25 March 2009 (UTC)

CIRP links

I will remove every instance of links to the CIRP library. There is no mention of copyright status of these articles; medical journals are copyright unless this is waived specifically. JFW | T@lk 15:08, 13 Feb 2005 (UTC)

• I raised the issue of the use of CIRP months ago. No one did a thing, when I deleted the stuff I was accused of deleting relevant information. What you now have inherited and which has drawn you into edit warring is of your own making. Good luck. - Robert the Bruce 04:01, 15 Feb 2005 (UTC)

Robert Blair: much better, but I rephrased the block quote into prose. I don't understand why you insist on listing the Fleiss book. You know it will get removed anyway. JFW | T@lk 00:19, 14 Feb 2005 (UTC)

Dr. Wolff, the book is written by a medical doctor. It devotes four pages to cervical cancer and it is appropriate in view of your insistence on including the dubious Castelsague paper. If you are going to introduce a discussion of male circumcision to push your pro-circumcision POV then you have to admit opposing viewpoints. Robert Blair 00:52, 14 Feb 2005 (UTC)

w00t, four pages! This page is about cervical cancer, not about circumcision. If this medical doctor had methodological issues with the Castelsague paper, he should have written to the New England Journal of Medicine. I am not pushing any POV: someone else inserted that article. I am still weary of you removing it, because that is just as POV. Now show me a critique of that paper published in a peer-reviewed journal, and we'll talk again. JFW | T@lk 07:25, 15 Feb 2005 (UTC)

• Tread carefully now as the way you are heading is that the usual vexatious litigants will have you up before the ArbCom for removing relevant information. And with that set up you will be facing a year long ban. You had your chance to nip this in the bud ... but failed to take the opportunity ... now you will have to live with the consequences. - Robert the Bruce 18:24, 15 Feb 2005 (UTC)

Ooooh, I'm really scared now. JFW | T@lk 21:05, 15 Feb 2005 (UTC)

ACS

From the American Cancer Society Website: http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_cervical_cancer_8.asp?rnav=cri

"...condoms do not protect against HPV..."

"...certain types of sexual behavior increase a woman's risk of getting HPV: sex at an early age, having many sexual partners, having sex with uncircumcised males..."

"...it is necessary to have had HPV for cervical cancer to develop..."

Yes, but dropping names in the intro distracts from the content. Just stop changing it. JFW | T@lk 22:06, 25 May 2005 (UTC)

More on HPV, please show how that ACS actaully arrrived that that conculsion beofer you keep adding the informtation to the article--nixie 04:51, 26 May 2005 (UTC)

214.13.4.151 (talk · contribs) puts in the edit summary: "rv to reflect accurate medical information". The other version was not inaccurate, but 214.13.4.151 is being a nasty POV-pusher like on many other pages on the project. If this carries on a request for comment is inevitable. JFW | T@lk 13:37, 29 May 2005 (UTC)

I tweaked again. Please let me know if there is a problem with the laest version. 214.13.4.151 13:45, 2 Jun 2005 (UTC)

there has recently been a new vaccine created in Australia

All of this chatter about the suggested association between smegma and cervical cancer is pointless. Cervical Cancer is CAUSED by HPV... period. Therefore, one who argues the POV that circumcision contributes to this disease should focus their attention on the fact that HPV can survive under the foreskin... that is, if they wish to attempt to discuss a subject which should only deserve - at the most - a few lines within the Cervical Cancer header. William R. Lewis, author, "Fatal Probe", 2003

Treatment section: Trachelectomy

Hi, My name is Amy. This was my first contribution to wikipedia. I wrote the 2nd paragraph on trachelectomy. I'd like any feedback anyone has.Aes333 16:47, 16 June 2006 (UTC)

Amy, are you sure you added the text you think you added? All I saw was your signature in the article (which I reverted back out; we don't sign contributions to the article, just to the talk pages). You can use the article's "history" page to see the differences that you and I have introduced. (Be sure you're looking at the article when you press "History" or you'll get the history of the talk page!)

Atlant 19:31, 16 June 2006 (UTC)

I added the trachelectomy section under treatment. I initially had a screen name of amys333 and changed it to aes333. Aes333 19:20, 18 June 2006 (UTC)

Female cancer Programme query

Someone added a link to Female cancer Programme, which another editor reverted. The organisation looks legit to me, being backed by the Dutch lottery &c. Do any Dutch people have more info on it, so we can decide? Nunquam Dormio 15:11, 13 September 2006 (UTC)

I reverted while watching TV. I am sorry, random spam-watch collateral damage. HawkerTyphoon 15:13, 13 September 2006 (UTC)

Death statistics inaccurate

"Worldwide, cervical cancer is the second most common cancer in women (after breast cancer) and is the third leading killer (behind breast and lung cancer)."

I can't find any citation that claims this; [1] and [2] seem to contradict that claim, however.

Actually, it's not a strict contradiction, since the WHO site claims cervical cancer is number five by number of deaths, while the original page claims it is number two by number of cases. However, given the ratio in the US between deaths and cases (which is far lower than the global average), it would be highly unlikely for it to be the second most prevalent by cases but fifth by deaths.

Additionally, the claim that it was the third greatest killer of women was directly contradicted by the above linked site. In any case, I've attempted to remove the offending claims and insert the correct ones. Sadly, I don't have sufficient references to provide accurate information on prevalence by cases, only on prevalence by death rates. S. Ugarte 06:15, 2 March 2007 (UTC)

Staging section misformatted

It looks like the last part of the staging subsection ended up under the Pathologic types subsection. However, I'm not an expert in any way or form, so I'm hesitant to edit the page. Can someone more knowledgeable please check this out?

84.105.95.194 11:17, 1 December 2007 (UTC)

Australian Cervical Cancer Foundation

A new organisation, the "AUSTRALIAN CERVICAL CNACER FOUNDATION" (accf.org.au) has been formed to provide "free of any charge" HPV cervical cancer vaccine (like Gardasil) to developing countries. The first country is Nepal, with which ACCF will commence an annually sustainable immunisation program building to providing 10,000 full rounds of HPV vaccinationations per year. The Nepalese HPV immunisation program will be launched at the Australian Embassy in Kathmandu on 8 March 2009 by His Excellency, Mr. Graeme Lade, Australian Ambassado to Nepal.

Professor Ian Frazer, who is the individual responsible for developing Gardasil and is also a Director of the Australian Cervical Cancer Foundation, will be in attendance. Additional Directors of ACCF include Michael Wille OAM, Lenore Guthrie, Linda Lavarch MP and Dr Surendra Shrestha of INCTR/NNCTR Nepal. For detailed information, see their their website, accf.org.au.—Preceding unsigned comment added by Michael wille (talk • contribs) 02:31, 29 December 2007

Unclear sentence

I moved the sentence below sentence to here from Papilloma virus section, since I'd like it to be more clear. It was already clearly stated that human papillomavirus increases risk of cervical cancer, so as far as I can see, it doesn't really contribute with anything new, although having reference:

Although most HPV infections clear up on their own, the infections could increase to major abnormalities or cervical cancer.

Mikael Häggström (talk) 19:26, 19 February 2008 (UTC)

The point of the sentence is that the immune system suppresses most HPV infections, so they clear up without intervention or causing disease, only a small proportion of infections lead to disease. This is important to say - since the vast majority of HPV infections do not lead to cancer. Would something like this make it clearer?

Although most HPV infections are cleared by the immune system, a few could lead to major abnormalities or cervical cancer.

Zodon (talk) 20:16, 19 February 2008 (UTC)

Incorrect information

Editors should be aware that the user user:Drsavard who proposed these changes does consulting work for QIAGEN pharmaceutical company, which is the owner of Digene, maker of the HPV test. Therefore they have a potential WP:COI regarding HPV testing. Zodon (talk) 05:52, 11 May 2008 (UTC)

I am a medical doctor specializing in internal medicine with 25 years of experience. I found the following information in this article to be incorrect and I’d like to update it to include the correct information. If no one protests the updates below within 48 hours, I’d like to go ahead and make these edits to ensure that Wikipedians receive the correct information as soon as possible. All references are included below.

Existing Text
An effective HPV vaccine against the two most common cancer-causing strains of HPV has recently been licensed in the U.S. (see Vaccine section, below). These two HPV strains together are responsible for approximately 70%[3][4] of all cervical cancers. Experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.

Updated Text
Experts recommend that women combine the benefits of both approaches by seeking regular Pap smear screening even after vaccination. In addition, the American College of Obstetricians and Gynecologists, American Cancer Society, and American Society for Colposcopy and Cervical Pathology agree that HPV testing, along with the Pap, is beneficial beginning at age 30.

Existing Text
More than 250 types of HPV are acknowledged to exist (some sources indicate more than 200 subtypes).

Updated Text
There are more than 100 types of HPV, with approximately 40 specifically affecting the genital area and around 15 that can cause cervical cancer.

Existing Text
While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix.

Updated Text
While both the Pap and HPV test are effective screening methods, diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix.

Existing Text
The HPV test is a newer technique for cervical cancer triage which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Since more than 99% of invasive cervical cancers worldwide contain HPV, some researchers recommend that HPV testing be done together with routine cervical screening (Walboomers et al, 1999). But, given the prevalence of HPV (around 80% infection history among the sexually active population) others suggest that routine HPV testing would cause undue alarm to carriers.

Updated Text
The HPV test is a newer technique for cervical cancer screening that detects the presence of human papillomavirus infection in the cervix. The U.S. Food and Drug Administration has to date approved one test for high-risk types of HPV, marketed as the digene® HPV Test. It is more sensitive than the Pap smear (less likely to produce false negative results), but somewhat less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Certain types of human papillomavirus (HPV) have now conclusively been shown as a necessary cause of cervical cancer, and both the American College of Obstetricians and Gynecologists and the American Cancer Society include routine screening for HPV for women age 30 and older (who are most at risk of developing cervical cancer) in their practice guidelines. (The organizations say that younger women should be tested for HPV only if their Pap is inconclusive.) But, given the prevalence of HPV, (around 80% of women are expected to get a genital type of HPV infection by the age of 50) other healthcare professionals suggest that routine HPV testing could cause undue alarm to carriers.

Drsavard (talk) 14:08, 10 March 2008 (UTC)

Please don't make the changes yet. Several of the changes you propose might easily mislead people. (e.g. about the value of HPV screening). The wording you propose might make it seem that HPV screening is valuable for all women over 30 (which has not been demonstrated), or that ACS and ASCCP recommend it for all such. Since this is not the case, it use could clarification. Some of the issues I have mentioned in feedback on other edits you proposed might also help improve this. I regret that I haven't the time right now to do a more thorough review of this proposal, so I don't know if there are other issues, but expect to be able to in a day or so, when I may have time to offer more assistance. Thanks. Zodon (talk) 08:45, 11 March 2008 (UTC)

Oppose addition of HPV testing to the summary in the form suggested. There is no evidence that HPV testing is valuable for screening in the absence of abnormal Pap. Since HPV test by itself costs more than a Pap smear it is not a cost-effective add-on.

2nd edit - no opinion. I have noticed lots of different numbers of types floating about here. It will be nice to get some of them tied down with citations.

3rd edit - oppose inclusion of HPV test there in diagnosis, discussion of the effectiveness of HPV testing should be limited until its value is generally proved/accepted.

Last edit - change from triage to screening okay if you have a citation indicating it has value for screening. Otherwise, suggest leave it. Do the ACS & ACOG actually recommend HPV testing? The wording used here could mean anything. Would be nice to make it more precise. If memory serves, HPV testing related to screening interval, but since screening every 3-5 years is the norm many places, and is consistent with USPSTF guidelines in USA, HPV testing need not be considered a prerequisite for that. So a bit more detail on what HPV testing has really been shown to be good for would help. (Both on the NPOV and in improving international scope.) Hope this help. Zodon (talk) 04:10, 13 March 2008 (UTC)

Thanks for your response; I appreciate your desire to work with me on making this page as up to date and helpful to readers as possible. However, I believe my edits accurately reflect the evolving medical data and expert consensus. Despite the fact that many community-based healthcare professionals are not yet routinely screening women age 30+ for HPV, along with a Pap, there is a large amount of clinical data supporting this use. I have inserted below a bibliography (with short summaries) of just a few of the recent publications, including the NEJM in October. (You commented on the cost-effectiveness of HPV testing: Note the study by Sue Goldie et al, published in the Journal of the National Cancer Institute, which concludes HPV testing is more effective in detecting pre-cancerous changes than standard cytology.) My colleagues who attend the international conferences where the latest research is discussed tell me that this issue has been settled long ago; the experts have now moved on to other topics, such as whether the HPV test should replace the Pap as the first-line screening tool.

You also ask about what the professional guidelines say. Both the ACS and ACOG guidelines state that healthcare professionals can either use more frequent Pap testing or combine cytology with HPV testing every three years (assuming normal results) for women age 30+. (The USPSTF is extremely conservative and often lags well behind the science before changing its guidelines. For instance, it insists on U.S. data that address specific questions, despite the presence of substantial clinical research conducted elsewhere.) However, in its most recent practice bulletin, ACOG said: “Because HPV DNA testing is more sensitive than cervical cytology, women with negative concurrent test results (negative cytology and negative HPV DNA) can be reassured that their risk of unidentified CIN 2 and CIN 3 or cervical cancer is approximately 1 in 1,000.” In addition, in a letter supporting a proposed bill to require insurance coverage of routine HPV testing, the CA chapter of ACOG said: “Pap tests are not as useful as HPV DNA diagnostic techniques in detecting the virus (HPV). Early detection using the latest technology will lead to better outcomes.” In fact, a study in the JNCI found that nearly one-third of cervical cancer cases can be attributed to Pap detection failure. Although many physicians believe that the use of liquid-based cytology reduces that failure rate, several recent studies – including one in The Lancet -- found no significant difference compared to conventional Paps. This is the basis for combining cytology with HPV testing, which is much better able to identify women at risk. There is a wealth of clinical data supporting the use of routine HPV testing of women age 30+, in conjunction with cytology. Below is just a sampling of these studies, beginning with the most recent: • Study results suggest that, in women aged 30 + years, co-testing with a Pap smear and HPV DNA test was more sensitive than reflex HPV testing for the detection of high-grade cervical lesions (91% vs. 54%), provided women with a positive hc2 test and negative Pap were referred to colposcopy and biopsy. Janet G. Baseman, Ph.D., Department of Epidemiology, University of Washington (American Journal of Obstetrics & Gynecology, March 2008)

• For both vaccinated and unvaccinated women, age-based screening by use of HPV DNA testing as a triage test for equivocal results in younger women and as a primary screening test in older women is expected to be more cost-effective than current screening recommendations. Sue J. Goldie MD, MPH, Department of Health Policy and Management, Harvard School of Public Health (Journal of the National Cancer Institute, Feb. 26, 2008) • Compared with cytology, HPV testing has greater sensitivity for the detection of cervical intraepithelial neoplasia. The sensitivity of HPV testing for CIN grade 2 or 3 was 94.6%, whereas the sensitivity of cytology alone was 55.4%. The sensitivity of both tests used together was 100%, and the specificity was 92.5%. Franco, E. et al. Human Papillomavirus DNA versus Papanicolaou Screening Tests for Cervical Cancer. New England Journal of Medicine 2007; 357: 1579-1588.

• Implementation of HPV DNA testing in cervical screening led to a substantial increase in the number of CIN 2/3+ lesions detected at the baseline screening round. At the subsequent round, combined HPV DNA and cytological testing was used in both study groups and significantly fewer CIN 2/3+ lesions were seen in the women who received both tests at the baseline round than in the control group. Therefore, the results show that implementation of HPV DNA testing in cervical screening leads to earlier detection of clinically relevant cervical lesions. Meijer, C. et al. Human papillomavirus DNA testing for the detection of cervical intraepithelial neoplasia grade 3 and cancer: 5-year follow-up of a randomized controlled implementation trial. The Lancet 2007; DOI:10.1016/S0140-6736(07)61450-0.

• HPV testing in primary screening and HPV vaccination against the most common types have the potential to reduce the incidence of invasive adenocarcinoma. Castellsague, X. et al. Worldwide Human Papillomavirus Etiology of Cervical Adenocarcinoma and Its Cofactors: Implications for Screening and Prevention. Journal of the National Cancer Institute 2006; 98: 303-315. • HPV testing is substantially more sensitive in detecting CIN 2+ than cytology (96.1% vs. 53%) but is less specific (90.7% vs.96.3%). In this analysis, the sensitivity of HPV testing was similar in all studies carried out in different areas of Europe and North America, whereas the sensitivity of cytology was highly variable. These results support the use of HPV testing as the sole primary screening test, with cytology reserved for women who test HPV-positive. Cuzick, J. et al. Overview of the European and North American studies on HPV testing in primary cervical cancer screening. International Journal of Cancer 2006; 119: 000-000. • HPV testing alone was more sensitive than conventional cytology among women 35- 60 years old. Adding liquid-based cytology improved sensitivity only marginally, while increasing false-positives. HPV testing using Hybrid Capture 2 with a 2 pg/mL cutoff may be more appropriate than a 1 pg/mL cutoff for primary cervical cancer screening. Ronco, G. et al. Human Papillomavirus Testing and Liquid-Based Cytology: Results at Recruitment From the New Technologies for Cervical Cancer Randomized Controlled Trial. Journal of the National Cancer Institute 2006; 98: 765 – 74.

• Because HPV DNA testing is more sensitive than cervical cytology in detecting CIN 2 and CIN 3, women with negative concurrent test results can be reassured that their risk of unidentified CIN 2 and CIN 3 or cervical cancer is approximately 1 in 1,000. ACOG Practice Bulletin No. 61, "Human Papillomavirus. Clinical Management Guidelines for Obstetrician-Gynecologists." April 2005. • The negative predictive value of combined HPV/Pap testing is 99.21% for CIN 3. Sherman M.E., et al. Human Papillomavirus Testing, and Risk for Cervical Neoplasia: A 10-Year Cohort Analysis. Journal of the National Cancer Institute, 2003;95:46-52.

• In another study of more than 11,000 women, the digene HPV Test was shown to be 97% sensitive for CIN 2+, compared to 77% for conventional Paps resulting in ASC-US or abnormal results. The study also documented that women infected with high-risk HPV and who have normal or borderline cytology can be managed as effectively with repeat testing after 12 months with immediate colposcopy. Cuzick, J. et al. Management of women who test positive for high-risk types of human papillomavirus: the HART study. The Lancet 2003;362:1871-76. • Still another study demonstrated that HPV testing is a more sensitive indicator of high-grade CIN than either conventional or liquid cytology alone. Screening with both an HPV and Pap test offered a sensitivity and negative predictive value of almost 100%. Twenty-one percent of women who were persistently positive for high-risk HPV DNA types when tested with hc2 were diagnosed with CIN 2/3 within 36 months, compared to only 0.08% of women who were initially HPV-negative. Lorincz, A., Richart, R. Human Papillomavirus DNA Testing As An Adjunct To Cytology In Cervical Screening Programs. APLM 2003;127:959-968. • A study of 8,466 women undergoing routine cervical cancer screening showed that when used in conjunction with a Pap, the sensitivity of the digene HPV Test test was 100% for detection of CIN 2+, while that of the Pap alone was 43.5%. Petry K., et al. Inclusion of HPV testing in routine cervical cancer screening for women above 29 years in Germany: results for 8,466 patients, British Journal of Cancer,2003;88:1570-1577. • Women with persistent HPV infection are more than 300 times more likely than HPV-negative women to develop high-grade cervical disease. Bory J., et al. Recurrent Human Papillomavirus Infection Detected with the Hybrid Capture 2 Assay Selects Women with Normal Cervical Smears at Risk for Developing High Grade Cervical Lesions: A Longitudinal Study of 3,091 Women. Int. J. Cancer, 2002;102:519-525. • In an ASC-US population, the sensitivity of the digene HPV Test for detecting high-grade precursors and cervical cancer is 96%, compared to 85% for a repeat liquid-based Pap test. Solomon D., et al. Comparison of Three Management Strategies for Patients with Atypical Squamous Cells of Undetermined Significance: Baseline Results from a Randomized Trial, J. Nat Cancer Inst, 2001; 93:293-299. • A cohort analysis of 5,671 women older than 30 (conducted within a larger study of 7,932 women) showed that conventional cytology was 57% sensitive for HSIL; liquid cytology was 84% sensitive, and the digene HPV Test was 100% sensitive. Clavel C., et al. Human Papillomavirus Testing in Primary Screening for the Detection of High-Grade Cervical Lesions: A Study of 7,932 Women. Brit J Cancer, 2001; 89 (12):1616-1623. • High-risk HPV types have been detected in 99.7% of cases of cervical cancer, confirming that the virus must be present for cervical cancer to develop. Walboomers J.M.M., et al. Human Papillomavirus is a Necessary Cause of Invasive Cervical Cancer Worldwide. Journal of Pathology 1999;189:12-19. Drsavard (talk) —Preceding comment was added at 16:18, 25 April 2008 (UTC)

Specificity is much more important for a screening test than sensitivity. The less specific the test, the more individuals will be referred for further testing. So if HPV testing is less specific and more sensitive this does not suggest that it will make a superior screening test. (Rather the reverse).

Since cervical cancer is slow developing on average there are lots of chances to detect it. Focuses on sensitivity arise because many don't understand the term or the differences between screening and diagnostic testing. (Or from medico-legal concerns.) Most of the cervical cancers in the US occur in people who haven't been screened recently, or who didn't get proper follow-up.

Since the HPV test currently costs more than twice as much as a Pap test it would have to do considerably better at reducing follow-up testing (i.e. be much more specific) and/or better at preventing cervical cancer to be cost-effective.

The USPSTF is conservative in it's guidelines in part because it is tasked with providing evidence based recommendations. The other recommendations list HPV testing as an option, not as a recommendation. HPV testing is not required for less-frequent screening under those guidelines. ACS recommends that pap screening be every 2 years if liquid based. And they acknowledge that it is safe for most women to be screened every 3 years, without HPV testing. Zodon (talk) 05:52, 11 May 2008 (UTC)

I disagree with " But, given the prevalence of HPV, (around 80% of women are expected to get a genital type of HPV infection by the age of 50)". Since only 15, of the 40 types that infect the genital area, cause cervical cancer, statistics should be restricted to those 15 types, not any type.--Nutriveg (talk) 19:04, 17 May 2010 (UTC)

Hysterectomy as usual/first line treatment?

The article says "Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.[18]"

I would say that the loop thing is often tried first, before considering a hysterectomy, as it can be done under local anaesthetic. Well, that's what I've heard, but then most ladies I would have discussed it with are of child-bearing age. Is the loop usually used as a first attempt on diagnosed cancer on all women? Only at the moment the article seems to suggest doctors tend to go straight for a hysterectomy, when I don't think they would tend to go straight for major surgery without trying other things first, along with chemo or something of course. Sticky Parkin 13:51, 19 August 2008 (UTC)

Wow, I have found this page to be very intersting, and would hope in the shortest possible time to be effectively participating in editing some of the articles. In the meantime, I must say: Thank you to all those who spare their precious time to contribute towards peoples awareness —Preceding unsigned comment added by 212.60.65.240 (talk) 11:57, 29 September 2009 (UTC)

Tumor markers

There are many tumor markers for cervical cancer, none of which have been universally accepted. This should be added. E.g. from PMID 17964182 . --Steven Fruitsmaak (Reply) 20:50, 6 October 2008 (UTC)

"Weak evidence"

Wow, no one's read this discussion page since 2008. Well, I was noticing the sub-section about vitamin A and saying that there's "weak evidence" supporting that vitamin A prevents CIN 1. If the evidence is "weak", then why is it there at all? Those seem to be pretty subjective terms. ForestAngel (talk) 03:02, 25 September 2009 (UTC)

External Review Comments

The following comments are from an external reviewer BSWSJR as part of the new joint Wikipedia talk:WikiProject Medicine/Google Project. I would like to introduce myself as a new editor for this project. This will be my first revision. My aim is to shore up the references and provide the most current information about cervical cancer. I also would like to revise the article to address a putative audience who would like to get information about diagnosis and prevention of cervical cancer. —Precedingunsigned comment added by BSWSJR (talk •contribs) 22:33, 20 May 2010 (UTC)

Introductory paragraph

I would suggest that the citation needed for the sentence ending with "has reduced the incidence of invasive cervical cancer by 50% or more." be American Cancer Society. Cervical Cancer: Prevention and Early Detection. Available at:http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Cervical_Cancer_Prevention_and_Early_Detection_8.asp. Also, change the first part of the sentence to "In the United States,". BSWSJR (talk) 04:22, 8 May 2010 (UTC)

This paragraph should include a reference to a basic diagram of the female reproductive system. I suggest an image like this one from the CDC website http://www.cdc.gov/cancer/cervical/. I would add--"The cervix is located at the lower end of the uterus (also known as the birth canal). The cervix connects the uterus to the vagina (for more details see http://en.wikipedia.org/wiki/Cervix). Most cervical cancers can initiate in cells that line the cervix. There are two main types of cells that cover the cervix: the squamous cells that lie closer to the vagina and the glandular cells that lie closest to the uterus. About 80-90% of cervical cancer originates from the squamous cells (squamous cell carcinoma) and the rest initiate from the glandular cells (adenocarcinoma). Cervical cancer is diagnosed by taking a sample from the cervix (pap smear) and looking at the type of cells under a microscope. Based on this type of analysis cervical cancer is classified."BSWSJR (talk) 19:30, 19 May 2010 (UTC)

Do you have sources for that? "About 80-90% of cervical cancer originates from the squamous cells (squamous cell carcinoma)". Please add new comments in the end of the talk page.---Nutriveg (talk) 19:45, 19 May 2010 (UTC)

Yes http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_is_cervical_cancer_8.asp from the ACS: What is Cervical Cancer webpage. BSWSJR (talk) 20:49, 19 May 2010 (UTC)

I don't think that source as a US public guide is a good source by Wikipedia standards.

(Rohan, 2004) says 75% (by 1998) and growing incidence of adenocarcinomas, it also cites "mixed adenosquamous tumors" beyond adenocarcinomas

Thomas E. Rohan, ed. (2004). Cervical Cancer: From Etiology to Prevention. Springer. ISBN 978-1402014109.

--Nutriveg (talk) 21:30, 19 May 2010 (UTC)

I will give you a second web reference from the National Cancer Institute (NCI) which is part of the National Institute of Health (NIH) under their health profession reviewed page http://www.cancer.gov/cancertopics/pdq/treatment/cervical/HealthProfessional/page3 where they say that 90% is squamous cell carcinoma. I also want to point out that on this page of the NCI site http://www.cancer.gov/cancertopics/pdq/treatment/cervical/HealthProfessional/page2where they have a general overview of cervical cancer their first reference for statistics is from the ACS website. It does seem that ACS compiled data is comparable to WHO and other accepted sources. BSWSJR (talk) 18:53, 20 May 2010 (UTC)

I see a problem because those sources don't cite their references for checking, they also seem to be very lay and country specific.--Nutriveg (talk) 19:21, 20 May 2010 (UTC)

Please look at references #10, #34, #46 and even #23(webMD) that all refer directly to ACS sites and statistics. References #5 and #13 are from the NCI site. Taking cues from these previous references I believe my recommended sources are also valid. The "lay" aspect you mention is mirrored in the references I mentioned in the previous sentence. This is what I mean by counterproductive. This will be the last time I directly rebut your points. BSWSJR (talk) 20:09, 20 May 2010 (UTC)

Diagnosis

The staging section should have a reference. I suggest http://www.bgcs.org.uk/media/7f4b5fd0dd26474db0ae97073639d15b.pdf. BSWSJR (talk) 05:45, 21 May 2010 (UTC) Under pathologic types the reference for squamous cell carcinoma percentage should be ttp://www.cancer.gov/cancertopics/pdq/treatment/cervical/HealthProfessional/page3 where they say that 90% is squamous cell carcinoma.99.161.157.28 (talk) 06:01, 21 May 2010 (UTC)

Prevention

I would recommend moving the whole section entitled Screening to be the first part of the section entitled Diagnosis. BSWSJR(talk) 20:42, 19 May 2010 (UTC) I also think it is misleading to have VIA as the main source of diagnosis when it is used as an alternative to Pap test in developing countries. BSWSJR (talk) 22:21, 20 May 2010 (UTC)

From my understanding that section id about "premalignant changes in the cervix" and "hpv infection (by specific types)" which is a different thing than "Cervical Cancer", so they belong to "Prevention" in my opinion.--Nutriveg (talk) 20:51, 19 May 2010 (UTC)

I disagree because a Pap smear and subsequent HPV detection are methods that allow for a diagnosis of pre-malignant changes in the cervix. I would also remove the statement that says the Pap test is a method to prevent cancer. If you look at the other sections in Prevention they specifically address procedures (e.g. vaccination, lower susceptibility behaviors, and diet that could lead to prevention. BSWSJR (talk) 21:02, 19 May 2010 (UTC)

The article intro defines "Cervical cancer is malignant neoplasm", so "premalignant changes in the cervix" and "hpv infection (by specific types)" are not cervical cancer. Cervical cancer can be prevented if those previous alterations are treated.--Nutriveg(talk) 21:35, 19 May 2010 (UTC)

Merck also puts pap test as prevention.---Nutriveg (talk) 21:41, 19 May 2010 (UTC)

I've separated the prevention section by David S. Alberts, ed. (2008). Fundamentals of Cancer Prevention. Springer. ISBN 978-3540689850.--Nutriveg (talk) 22:07, 19 May 2010 (UTC)

Again the PAP test in your Merck reference is first described in the Diagnosis section. Also, there is a statement that the PAP test combined with treatment is preventative. I want to say I think this is counterproductive to the editing process. I am striving to find the most recent and relevant information. BSWSJR (talk) 18:53, 20 May 2010 (UTC)

Merck "also" uses, it's not the same as "moving the whole section" which as in Merck remains mainly in the prevention section. Exactly what is is counterproductive?--Nutriveg (talk) 19:17, 20 May 2010 (UTC)

Let me be clear the PAP test needs to be mentioned at the beginning of the Diagnosis section along with information about following up a PAP test result with an HPV DNA test. Information about how often and at what age the PAP test should be administered should stay in the prevention section. BSWSJR (talk) 20:09, 20 May 2010 (UTC)

Under the Nutrition subsection the reference needed Coenzyme Q10 should be Palan PR, Mikhail MS, et al. Plasma concentrations of coenzyme Q10 and tocopherols in cervical intraepithelial neoplasia and cervical cancer. Eur J Cancer Prev . 2003 Aug;12(4):321–6. 99.161.157.28 (talk) 06:30, 21 May 2010 (UTC)

As I understand it the majority of cases of cervical cancer are due to an STD correct? That being the case shouldn't prevention include discouraging sleeping around? Seems pretty obvious so I'm surprised it's not been mentioned, especially since the article uses very qualified language (may protect etc) in relation to condoms. Prevention is better than cure, which is why Gardasil is viewed so favourably, except that's not a preventative it's an immunisation. —Precedingunsigned comment added by 203.25.1.208 (talk) 21:44, 11 April 2011 (UTC)

Causes

The first sentence under the HPV section should have a reference. I suggest this one for a new study relating HPV infection with adenocarcinoma Prospective study of human papillomavirus and risk of cervical adenocarcinoma.Dahlström LA, Ylitalo N, Sundström K, Palmgren J, Ploner A, Eloranta S, Sanjeevi CB, Andersson S, Rohan T, Dillner J, Adami HO, Sparén P Int J Cancer. 2010 Apr 19. BSWSJR(talk) 23:29, 20 May 2010 (UTC) I also suggest this older reference about a prospective study correlating HPV 16 and 18 with squamous cell cervical cancer Prospective seroepidemiologic study of human papillomavirus infection as a risk factor for invasive cervical cancer.Dillner J, Lehtinen M, Björge T, Luostarinen T, Youngman L, Jellum E, Koskela P, Gislefoss RE, Hallmans G, Paavonen J, Sapp M, Schiller JT, Hakulinen T, Thoresen S, Hakama M. J Natl Cancer Inst. 1997 Sep 3;89(17):1293-9. BSWSJR (talk) 23:48, 20 May 2010 (UTC) Finally, an older study establishing the general link between HPV and cervical neoplasia is: Schiffman MH, Bauer HM, Hoover RN, et al.: Epidemiologic evidence showing that human papillomavirus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 85 (12): 958-64, 1993. 99.161.157.28 (talk) 05:57, 21 May 2010 (UTC)

Cofactors

I think a proper reference for the HLA-B7 is Selected class I and class II HLA alleles and haplotypes and risk of high-grade cervical intraepithelial neoplasia. Ades S, Koushik A, Duarte-Franco E, Mansour N, Arseneau J, Provencher D, Gilbert L, Gotlieb W, Ferenczy A, Coutlée F, Roger M, Franco EL; Biomarkers of Cervical Cancer Risk (BCCR) Study Team Int J Cancer. 2008 Jun 15;122(12):2820-6. BSWSJR (talk) 23:12, 20 May 2010 (UTC)

Cause unknown

The cause of cervical cancer is unknown. This claim may be referenced to a number of reliable sources:

• Stuart Campbell; Ash Monga (2006). Gynaecology by Ten Teachers (18 ed.). Hodder Education. ISBN 0340816637.
• http://www.oncologychannel.com/femalecancers/index.shtml
• http://www.gyncancer.com/cervix.html
• http://www.cancer.org.au/aboutcancer/cancertypes/cervicalcancer.htm
• ... ([3]

The majority of women infected by HPV never get cancer. --Eleassar ^{my talk} 10:14, 21 September 2010 (UTC)

To say that "The cause is unknown" is misleading. It implies that there is a single cause (which there need not be; in this case there is no reason to expect a single cause). If that is the issue, please provide WP:MEDRS that back up the claim that there is a single cause (i.e. that saying "the cause" makes sense).

We do know some of the causes of cervical cancer. To say that the cause is unknown and then to say we know a necessary cause (HPV infection) is contradictory and confusing.

I modified it to. "Not all of the causes of cervical cancer are known." Does that get more at the meaning you are thinking of?

If not - what sort of cause are you concerned with not being known? (i.e. please explain the concern in more detail). 02:22, 22 September 2010 (UTC)

The proposed phrasing is ok. --Eleassar ^{my talk} 19:08, 22 September 2010 (UTC)

I do not know any cancer where the "cause is known". Carcinogenesis is a complex process, it would be more appropriate to say something along the lines "while some causes are suspected and epidemiologically substantiated the conditions and the process of carcinogenesis are far from being completely understood". Richiez (talk) 09:38, 23 September 2010 (UTC)

As far as I know, Cervical cancer is somewhat atypical in that there is a known, widely accepted necessary cause that applies to virtually all cases. "The presence of HPV in virtually all cervical cancers implies the highest worldwide attributable fraction so far reported for a specific cause of any major human cancer." (Walboomers 1999) (i.e., it comes closest at that time to having "A cause," that cause being HR HPV infection).

How about shortening Richiez's suggestion to something like "While some causes are known, the conditions and the process ofcarcinogenesis is not completely understood." Zodon (talk) 19:42, 25 September 2010 (UTC)