Evaluation of a public expense-covered gynecologic screening program in Japan 2005-2009

doi:10.4236/ojog.2011.12005

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Open Journal of Obstetrics and Gynecology, 2011, 1, 21-24

doi:10.4236/ojog.2011.12005 Published Online June 2011 (http://www.SciRP.org/journal/ojog/ OJOG

Published Online June 2011 in SciRes. http://www.scirp.org/journal/OJOG

Evaluation of a public expense-covered gynecologic screening

program in Japan 2005-2009

Hiroshi Takagi, Satoshi Ichigo, Kazutoshi Matsunami, Atsushi Imai*

Department of Obstetrics and Gynecology, Matsunami General Hospital, Kasamatsu, Gifu, Japan.

Email: *[email protected]

Received 14 April 2011; revised 31 May 2011; accepted 8 June 2011.

ABSTRACT

Introduction: In Japan, there is free physical check-

up programs of cancer screening, by which asymp-

tomatic participants undergo a medical examination

at public expense. The present study aims to describe

their gynecologic findings and compare them with the

literatures reported from general hospitals and self-

paid check-up programs. Methods: Medical records

of Japanese women, who underwent gynecological

examinations at public expense between 2005 and

2009, were retrospectively reviewed. Results: Of the

cervical smears from 2850 women aged 21 - 82 years,

33 (1.1%) were classified as dysplastic and malignant

changes: 28 of low-grade squamous intraepithelial

lesion (LSIL), 3 high-grade squamous intraepithelial

lesion (HSIL), 2 atypical squamous cells of unde-

terimined significance (ASC-US). No case of cervical

squamous cell carcinoma or adenocarcinoma was

found. Ultrasonographic examination detected uterus

enlargements and ovary tumors in less than 1% of

cases. Most of participants (98%) revealed no gyne-

cologic abnormalities. Conclusion: Annual gyneco-

logic screening and proper follow-up programs even

against asymptomatic women may remarkably re-

duce the probability of (pre)malignant disease.

Keywords: Cervical Smear Screening; Transvaginal

Sonography; Gynecologic Check-up; Oncology

1. INTRODUCTION

Cervical intraepithelial neoplasia typically develops into

invasive cancer over a 10-year period and apparent cases

of rapidly progressive cervical cancer are likely to be

among women who have escaped screening and proper

follow-up [1-6]. The cervical smear (Papanicolaou, Pap

smear) is a routine screening test used for the detection

of early cervical abnormalities, namely precancerous

dysplastic changes of the uterine cervix [1-6]. Organized

screening programs for cervical cancer using the cervical

smears have been shown to be effective in decreasing

mortality and incidence from the disease [1,7]. The cer-

vical screening is a relatively simple, low cost and non-

invasive method. Together with transvaginal ultrasono-

graphy for detection of ovarian and uterine tumors, a

routine cervical screening reduces the probability of de-

veloping gynecological m a li gnant di seases .

In many countries, undergoing cancer screening is not

mandatory but voluntary. The level of knowledge and

attitude toward screening are related to multiple factors

such as ethnicity, place of residence, income, and social-

economic status [8-12]. In Japan, there are free physical

check-up programs of cancer screening, by which as-

ymptomatic participants undergo a medical examination

at public expense. The present study aims to describe

their gynecologic findings and compare them with the

literatures reported from general hospitals and self-paid

check-up programs.

2. METHODS

Between January 2005 and December 2009, 2850 as-

ymptomatic women, age 21-82, visited one of four Ka-

samatsu City-agreed gynecologic physicians for their

physical check-up. The cost was fully covered by the

municipal corporation. Gynecologic examinations in-

cluded routine cancer screening (Papanocolaou test),

transvaginal ultrasonography, and pelvic examination by

a gynecologist. Cervical and endometrial smears were

taken using a speculum and brush and classified into 6

categories: normal, low-grade squamous intraepithelial

lesions (LSIL), high-grade squamous intraepithelial le-

sions (HSIL), atypical squamouse cells of undetermined

significance (ASC-US), cervical carcinoma, cervical

adenocarcinoma. When classified as inadequate, the par-

ticipants were soon resubmitted to smear examination.

Their records of gynecologic findings were retrospec-

tively reviewed.

3. RESULTS

Table 1 shows the cytologic and ultrasonografic f indings

H. Takagi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 21-24

Table 1. Gynecologic findings of participants distributed by age.

Cytology

Cervix Endometrium

Age group,

years No. (%)

LSIL HSIL ASC-USSCCHyperplasia/cancer

Uterine tumor

and abnormalities1) Ovarian

tumor2) Others3)

20 - 24 26 (0.9) 1 (3.8) 0 0 0 0 0 0 0

25 - 29 94 (3.3) 1 (1.1) 0 0 0 0 0 1 (1.1) 0

30 - 34 282 (9.9) 5 (1.8) 0 1 (0.3) 0 0 0 1 (0.3) 0

35 - 39 400 (14.0) 5 (1.8) 1 (0.3) 0 0 0 0 1 (0.3) 0

40 - 44 398 (14.0) 4 (1.3) 1 (0.3) 0 0 0 1 (0.3) 1 (0.3) 2 (0.5)

45 - 49 259 (9.1) 3 (1.0) 1 (0.4) 1 (0.4) 0 0 6 (2.3) 1 (0.4) 1 (0.4)

50 - 54 257 (9.1) 3 (1.1) 0 0 0 0 3 (1.1) 0 1 (0.4)

55 - 59 299 (10.5) 1 (1.3) 0 0 0 0 1 (0.3) 0 0

60 - 64 287 (10.1) 1 (0.3) 0 0 0 0 1 (0.3) 0 0

65 - 69 281 (9.9) 1 (0.3) 0 0 0 0 1 (0.3) 1 (0.6) 0

70 - 74 172 (6.0) 2 (1.2) 0 0 0 0 0 1 (0.6) 1 (0.6)

75 - 79 76 (2.7) 1 (1.3) 0 0 0 0 0 0 0

<80 19 (0.7) 0 0 0 0 0 0 0 0

28 (1.0) 3 (0.1) 2 (<0.1) 0 0 13 (0.5) 7 (0.2) 5 (0.2)

Total 2850 (100) 56 (2.0)

1) adenomyosis and uterine myoma (measuring 5 to 9 cm). 2) unilobular cyst (measuring 3 to 5 cm) suggestive for benign mass. 3) including vaginosis, cervical

polyp, prolaps uteri.

of all subjects distributed by age class. Of the cervical

smears, 33 (1.1%) were classified as abnormal. Low-

grade cervical abnormalities were seen in 31 cases: 28

cases were classified as low-grade squamous intraepi-

thelial lesion (LSIL) and 3 as high-grade squamous in-

traepithelial lesion (HSIL), 2 were atypical squamous

cells of undetermined significance (ASC-US). No ma-

lignant case was detected within this study period. No

case of cervical adenocarcinoma was found. None of the

categories were clustered in any specific age group.

The most frequently detected gynecologic finding was

uterine enlargement, with a peak reaching approximately

10% for age group 45 - 49 years. After 55 years, the

frequency of uterine abnormalities decreased (Ta b l e 1 ).

Ovarian tumor was detected in less than 1% of those

aged 25 to 49 years, while those aged over 50 years

showed less frequent. Ta b le 1 summarized all other ab-

normal findings pointed out. No gynecologic abnormal-

ity was detected in 98% of cases.

4. DISCUSSION

The cervical smear is a widely used routine test with

many benefits, especially in detecting early cervical

changes that can be treated to limit dysplastic processes

developing into cancer. The previous literatures found

squamous intraepiterial lesion (SIL) in 3% - 8% of

women aged 20 - 29 years and 1% - 5% of over 30-year

age group [1-6]. Of the cervical smear tests on 7585

subjects in our study, 98.2% were negative. The inci-

dence of abnormal cytologic findings (dysplastic

changes and cervical cancer) in our study (1.2%) was

extremely low compared with other studies performed in

developed countries [1-6].

Substantial data point to persistent human papillo-

mavirus (HPV) infection as cervical cancer cause. The

mean time between HPV infection and invasive cancer is

about 15 years, and within 2 to 4 years of detection 15.5

to 25.5% of low-grade epithelial lesions become high-

grade lesions [13-15]. The most frequently sexually

transmitted disease (STD) worldwide is HPV infection

[16,17]. Societies where sexual activity starts at a young

age and where multiple partners are common are at high

risk of exposure to HPV than in conservative societies.

For example, a study in Jordan, one of the most conser-

vative and religious countries, found that of the smears

from 1176 women aged 18 - 70 years, 9 cases (0.8%)

were classified as ASC-US and 2 cases (0.2%) were

LSIL. Based on our result of city-agreed check-up, as-

H. Takagi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 21-24 23

ymptomatic participants undergo a medical examination

at public expense. The cultural tradition and high con-

cern on check-up of our subjects restrict the likelihood

of multiple sexual partners. This may explain why very

low incidence of dysplastic changes and cervical cancer

were found in our study group of women.

Of pelvic mass, uterine myomas and/or adenomyosis

are estimated to be present in 20% - 25% or reproduc-

tive-age women, indicating that they are one of the most

common human neoplasma [18-20]. A myoma does not

necessarily produce symptoms, and even very large ones

may go undetected by the patient, particularly if she is

obese. Symptoms from myomas depend on their location,

size and state of presentation; symptoms are present in

35% - 50% of patients with myomas. Ovarian tumors,

cystic or solid, are also frequently asymptomatic and

undetected by themselves. The diagnosis of these tumors

is not usually difficult using ultrasonography at physical

check-up. We observed lower frequency of uterine en-

largement and ovarian tumors in our subjects.

The present study based on symptom-free population

suggested annual gynecologic screening and proper fol-

low-up programs even against asymptomatic women

may remarkably reduce the probability of (pre) maliga-

nant disease. Since the study sample was shown to be

representative populatio n of high-attitu de toward screen-

ing but non-high income, most of our observations may

have important implications in terms of public health.

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