CMAJ 1997;157:497
© 1997 Canadian Medical Association
Papanicolaou (Pap) testing has helped reduce the incidence of cervical cancer in Canada to a rate of 8 per 100 000 women per year. To determine why -- in spite of this success -- invasive cervical cancer still occurs, Gavin Stuart and colleagues reviewed the case histories of 246 consecutive women who were diagnosed with this disease in 199091 (page 513). They found that 30% had never had a Pap smear and 15% had not been screened in the 3 years before diagnosis. In addition, 17% of the smears had been read incorrectly as normal. Thus, in addition to a failure to reach some women with screening, there was a failure of quality control in the laboratory.
Rates of cervical cancer in Newfoundland are about twice as high as in the rest of Canada. Sharon Buehler and Wanda Parsons at Memorial University identified 441 women at family medicine clinics who had not been screened in the previous 3 years and randomly selected half of them to receive a letter explaining the benefits of Pap testing and asking them to seek an appointment (page 521). The response was disappointingly modest; evidently, simple reminder letters to underscreened women are not sufficient.
In an accompanying editorial Eva Grunfeld dissects this failure (page 543). She notes that women fall into 3 broad groups: those who respond to screening if they understand its importance and can access it easily; those who respond to a more proactive approach such as a call/recall system; and those who are hard to reach. Women in the third group are likely to be aboriginal, immigrants, elderly or of low socioeconomic status -- that is, the very women at greatest risk of cervical cancer. Thus it is important that screening initiatives give particular attention to targeting hard-to-reach groups.
Infant mortality is an important indicator of population health. In this issue K.S. Joseph and Michael Kramer report that marked provincial variation in infant mortality rates persists (page 535). An important determinant of infant mortality is birth weight: infants with birth weights of < 2500 g account for 75% of all infant deaths. Between 1987 and 1994 low-birth-weight rates in Ontario increased by 22%, while in Quebec these rates decreased slightly, falling below the rates in Ontario. In attempting to understand this trend the authors discovered unusual patterns that suggested the Ontario data had been skewed by a persistent recording error. In an accompanying editorial Graham Chance voices alarm: "That such an error could have occurred suggests that those responsible for entering the data had little understanding of the importance of the material they were entering or of the basic difference between metric and imperial measures" (page 549).
Celiac disease, an eminently treatable condition, is underdiagnosed in North America. The only sure method of diagnosis, small-bowel biopsy, is usually done only in severe cases with a typical presentation. Thus, children with atypical symptoms are not diagnosed and continue to suffer. Lucie Chartrand and colleagues at the Université de Montréal evaluated a simple serologic and antigliadin antibody test in 176 children with possible celiac disease (page 527). The test had a sensitivity and specificity of 80% and 92%, respectively. George Davidson and Eric Hassall of the University of British Columbia recommend that serologic testing be used not only in children with classic symptoms, but also in those from high-risk groups or with merely suggestive symptoms (page 547). -- JH
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