Critical analyses of the introduction of liquid-based cytology in a public health service of the state of São Paulo, Brazil

OBJECTIVE The aim of this study was to compare the performance of the current conventional Pap smear with liquid-based cytology (LBC) preparations. STUDY DESIGN Women routinely undergoing their cytopathological and histopathological examinations at Fundação Oncocentro de São Paulo (FOSP) were recruited for LBC. Conventional smears were analyzed from women from other areas of the State of São Paulo with similar sociodemographic characteristics. RESULTS A total of 218,594 cases were analyzed, consisting of 206,999 conventional smears and 11,595 LBC. Among the conventional smears, 3.0% were of unsatisfactory preparation; conversely, unsatisfactory LBC preparations accounted for 0.3%. The ASC-H (atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion) frequency did not demonstrate any differences between the two methods. In contrast, the incidence of ASC-US (atypical squamous cells of undetermined significance) was almost twice as frequent between LBC and conventional smears, at 2.9 versus 1.6%, respectively. An equal percentage of high-grade squamous intraepithelial lesions were observed for the two methods, but not for low-grade squamous intraepithelial lesions, which were more significantly observed in LBC preparations than in conventional smears (2.2 vs. 0.7%). The index of positivity was importantly enhanced from 3.0% (conventional smears) to 5.7% (LBC). CONCLUSIONS LBC performed better than conventional smears, and we are truly confident that LBC can improve public health strategies aimed at reducing cervical lesions through prevention programs

Saúde bucal, práticas de higiene bucal e ocorrência de câncer da cavidade oral

OBJECTIVE: To assess the association between oral health and hygiene practices and oral cancer. METHODS: Hospital-based case-control study in the metropolitan area of São Paulo, southeastern Brazil, from 1998 to 2002. A total 309 patients with squamous cell carcinoma of the mouth and the pharynx and 468 controls matched by sex and age were included in the study. Cases were recruited in seven reference hospitals and controls were selected in five out of the seven participating hospitals. Detailed information on smoking, alcohol consumption, schooling, oral health status and hygiene practices were obtained through interviews. Odds ratios (OR) and 95% confidence intervals (95% CI), adjusted by sex, age, schooling, smoking, alcohol consumption as well as the variables oral health status and hygiene practices were estimated using unconditional logistic regression analyses. RESULTS: The use of complete dental prosthesis was not associated with oral cancer but regular gum bleeding showed a strong association (OR 3.1; 95% CI 1.2-7.9). Those who never attended a dental visit were more likely to have oral cancer (OR 2.5; 95% CI 1.3-4.8). Daily mouthwash use showed a stronger association to pharynx (OR 4.7; 95% CI 1.8-12.5) than mouth cancer (OR 3.2; 95% CI 1.6-6.3). CONCLUSIONS: Gum bleeding, no dental care, and daily mouthwash use were factors associated with oral cancer regardless of tobacco and alcohol consumption.OBJETIVO: Avaliar a associação entre saúde e higiene bucal na ocorrência de câncer oral. MÉTODOS: Estudo caso-controle de base hospitalar, realizado entre 1998 e 2002 na área metropolitana de São Paulo, SP. Foram incluídos 309 pacientes com carcinoma epidermóide de boca e orofaringe e 468 controles, pareados com os casos por sexo e idade. Os casos foram levantados em sete hospitais que concentram a assistência médica a pacientes com a doença e os controles rastreados em cinco hospitais gerais dentre os sete. Informações pormenorizadas sobre tabagismo, consumo de álcool, escolaridade, saúde bucal e práticas de higiene bucal foram obtidas por entrevista. Por meio de análise de regressão logística não condicional foram calculados odds ratios (OR) e intervalos com 95% de confiança (IC 95%), ajustados por sexo, idade, nível educacional, tabagismo e consumo de álcool, bem como para as demais variáveis de saúde e higiene bucal. RESULTADOS: Uso de prótese bucal total não se associou a câncer oral, mas sangramento gengival freqüente apresentou alta associação (OR=3,1; IC 95%: 1,2;7,9). Nunca ter consultado dentista mostrou associação com câncer oral (OR=2,5; IC 95%: 1,3;4,8). Uso diário de enxaguatórios bucais apresentou associação mais intensa com tumores de faringe (OR=4,7; IC 95%: 1,8;12,5) do que com tumores de boca (OR=3,2; IC 95%: 1,6;6,3). CONCLUSÕES: Sangramento gengival, ausência de consultas com dentistas e uso regular de enxaguatórios bucais foram fatores associados com câncer oral, independentemente de tabagismo e consumo de bebidas alcoólicas.European Commission ContractFundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

A morphological protocol and guide-list on uterine cervix cytology associated to papillomavirus infection

The present study was designed to further assess the validity of the cytological description of morphological lesions said to be related to Papillomavirus (HPV) infections in senior women. The casuistic comprised 196 cervical smears from a group of women with no clinical or morphological evidence of neoplasia, collected simultaneously with samples submitted to detection of HPV DNA by PCR in a previous study. Three experienced cytologists studied each slide in two different conditions, with an interval of 20 months between them. The first approach was performed under routine laboratory standards, whereas the second was guided by a list of 16 well-defined parameters indicative of HPV-related cytological lesions. When suspicious cases of HPV-related alterations were grouped with positive cases, they showed on average: sensitivity of 25.5%, specificity of 84.4% and positive predictive value (PPV) of 26.8%. When suspicious cases were grouped with negative cases, sensitivity decreased, whereas specificity and PPV increased, as expected. In the second reading, which followed a “guide-list”, a decrease in sensitivity was observed, contrasting with a sharp increase of positive predictive value. Among the 16 cytomorphological criteria tested, “koilocytosis”, “mild koilocytosis” and “condylomatous parabasal cells” yielded the best predictive value for HPV DNA detection by PCR. In conclusion, despite the low sensitivity, cytopathologic assessment of cervico-vaginal smears leads to a highly specific diagnosis of HPV infection in menopausal women, with PPV of 91.0% when directed by a guide-list of well-defined morphologic criteria.O presente estudo analisou aspectos relacionados ao valor da citologia cervical na identificação de alterações cito-morfológicas relacionadas à infecção por Papilomavírus humano (HPV) em mulheres com idades avançadas. A casuística compreendeu 196 amostras cérvico-vaginais provenientes de uma população de mulheres sem evidências clínicas ou citológicas de neoplasia cervical. As amostras foram coletadas simultaneamente para pesquisas para DNA-HPV por Reação de Polimerização em Cadeia (PCR) e citologia. Três observadores experientes efetuaram análise das lâminas em duas etapas com intervalo de 20 meses: a primeira em condições de rotina laboratorial e a segunda dirigida por um roteiro de critérios pré-estabelecidos. Quando os casos suspeitos para alterações relacionadas ao HPV foram agrupados com os casos positivos, eles mostraram em média: 25,5% de sensibilidade, 84,4% de especificidade e valor preditivo positivo (VPP) de 26,8%. Quando os casos suspeitos foram agrupados com os negativos, a sensibilidade diminuiu, e a especificidade e o VPP aumentaram. Na segunda leitura, a sensibilidade diminuiu, contrastando com o aumento do VPP. Entre os 16 critérios cito-morfológicos avaliados, coilocitose, coilocitose leve e célula parabasal coilocitótica foram os que apresentaram melhor VPP para HPV em comparação ao PCR. Concluímos que, apesar da baixa sensibilidade, o painel de critérios cito-morfológicos poderá elevar a especificidade do teste de Papanicolaou para triagem das alterações relacionadas à infecção por HPV em pacientes de mais idade

Seroprevalence of human papillomavirus 6, 11, 16, and 18 in young primiparous women in Sao Paulo, Brazil

INTRODUCTION: Data on epidemiology of HPV infection are needed for the development of human papillomavirus (HPV) vaccine recommendations, especially in countries where HPV vaccination is not yet included in public vaccination programs. The aim of this study was to determine the prevalence of serum antibodies to HPV types 6, 11, 16, and 18 and associated factors among young women after birth of the first child. METHODS: This cross-sectional study was carried out in a large public maternity hospital in Sao Paulo, Brazil. Three hundred one women aged 15 to 24 years who gave birth to their first child were recruited between 43 and 60 days after delivery. Seroprevalence was performed using a type-specific enzyme-linked immunosorbent assay based on HPV Late protein 1 viruslike particles. The association of seroreactivity with these 4 HPV types with selected demographic and behavioral factors was assessed by Generalized Linear Model analysis. RESULTS: Fifty-eight (19.3%) women (95% confidence interval, 15.0%-24.2%) had antibodies to any of the 4 viruslike particles tested. The overall seroprevalence rates of the HPV types were: HPV16, 9.0%; HPV18, 7.0%; and HPV 6+11, 7.7%, which are targeted by the HPV prophylactic vaccines. In the multivariate analysis, only age (inversely, P = 0.044 for trend) and previous sexually transmitted disease (P = 0.008) were 2 factors independently associated with HPV seropositivity. CONCLUSIONS: These data offer additional information on the epidemiology of HPV in a group of young Brazilian women after first delivery and contribute to establish a baseline of HPV seroprevalence against which post-HPV vaccine era seroprevalence can be compared. PMID: 21051985 [PubMed - indexed for MEDLINE]This study was supported by a research grant from the Department of Immunization, Vaccines and Biologicals, World Health Organization (ref: V20-181-13)

Padrões dietéticos e risco de câncer oral: estudo caso-controle em São Paulo

OBJECTIVE: To analyze the association between dietary patterns and oral cancer. METHODS: The study, part of a Latin American multicenter hospital-based case-control study, was conducted in São Paulo, Southeastern Brazil, between November 1998 and March 2002 and included 366 incident cases of oral cancer and 469 controls, frequency-matched with cases by sex and age. Dietary data were collected using a food frequency questionnaire. The risk associated with the intake of food groups defined a posteriori, through factor analysis (called factors), was assessed. The first factor, labeled prudent, was characterized by the intake of vegetables, fruit, cheese, and poultry. The second factor, traditional, consisted of the intake of rice, pasta, pulses, and meat. The third factor, snacks, was characterized as the intake of bread, butter, salami, cheese, cakes, and desserts. The fourth, monotonous, was inversely associated with the intake of fruit, vegetables and most other food items. Factor scores for each component retained were calculated for cases and controls. After categorization of factor scores into tertiles according to the distribution of controls, odds ratios and 95% confidence intervals were calculated using unconditional multiple logistic regression. RESULTS: Traditional factor showed an inverse association with cancer (OR=0.51; 95% CI: 0.32; 0.81, p-value for trend 0.14), whereas monotonous was positively associated with the outcome (OR=1.78; 95% CI: 1.78; 2.85, p-value for trend <0.001). CONCLUSIONS: The study data suggest that the traditional Brazilian diet, consisting of rice and beans plus moderate amounts of meat, may confer protection against oral cancer, independently of any other risk factors such as alcohol intake and smoking.OBJETIVO: Analisar padrões dietéticos relacionados com o câncer oral. MÉTODOS: Estudo caso-controle de base hospitalar, parte de um estudo multicêntrico na América Latina, foi realizado em São Paulo entre novembro de 1998 e março de 2003 em 366 casos incidentes de câncer oral e 469 controles, pareados por freqüência de sexo e idade. O inquérito dietético foi realizado por questionário de freqüência alimentar. Analisou-se o risco associado ao consumo de grupos de alimentos definidos a posteriori, por análise fatorial. O primeiro fator, denominado prudente, caracterizou-se pelo consumo de vegetais, frutas, queijos e aves. O segundo, tradicional, pelo consumo de arroz e massas, leguminosas e carne, enquanto o terceiro, lanches, pelo consumo de pão, manteiga, embutidos, queijos e doces. O último, monótono, associou-se inversamente ao consumo de frutas e vegetais, e a maior parte dos outros itens alimentares. Calculou-se um escore para cada padrão derivado, para casos e controles. Após categorização dos escores em tercis, de acordo com a distribuição dos controles, estimou-se a odds ratio e o intervalo de confiança de 95% por regressão logística múltipla não condicional. RESULTADOS: O padrão tradicional relacionou-se inversamente com o câncer oral (OR=0,51; IC 95%: 0,32; 0.81, p=0,140), enquanto o padrão monótono associou-se positivamente (OR=1,78; IC 95%: 1,78; 2,85, p<0,001). CONCLUSÕES: Os resultados sugerem que o prato tradicional do brasileiro, composto de arroz e feijão, mais quantidades moderadas de carne, pode conferir proteção quanto ao câncer oral, independente de outros fatores de risco reconhecidos, como consumo de álcool e tabaco.Universidade de São Paulo Faculdade de Saúde Pública Departamento de NutriçãoInstituto do Câncer Arnaldo Vieira de Carvalho Departamento de Cabeça e PescoçoHospital do Câncer A.C.Camargo Departamento de Cabeça, Pescoço e OtorrinolaringologiaHospital Heliópolis Departamento de Cabeça e PescoçoUniversidade Federal de São Paulo (UNIFESP) Departamento de Otorrinolaringologia, Cabeça e Pescoço. Hospital São PauloUSP FSP Departamento de EpidemiologiaUSP Faculdade de Medicina Departamento de Medicina PreventivaUNIFESP, Depto. de Otorrinolaringologia, Cabeça e Pescoço. Hospital São PauloSciEL

Assessing screening practices among health care workers at a tertiary-care hospital in Sao Paulo, Brazil

OBJECTIVE: To ascertain the extent to which screening procedures (with and without evidence of effectiveness) are practiced among health care workers at a tertiary-care hospital in Sao Paulo, Brazil. METHODS: From February 2001 to September 2003, a cross-sectional study involving physicians, nurses and nursing assistants (aged 40 to 69 years) was carried out at a tertiary-care hospital in the city of Sao Paulo, Brazil. Subjects were interviewed using a questionnaire that addresses 17 procedures with grades of recommendation of A, B, C, D or E, in accordance with the 1996 United States Preventive Services Task Force guidelines for routine screening. RESULTS: Of the 333 health care workers included, 228 (68.5%) were female. The mean age was 48.8 (SD 6.6 years). Most subjects had undergone screening for hypertension (blood pressure measurement) and lipid abnormalities (cholesterol testing). Screening for breast and cervical cancer was common among females. Resting electrocardiography, serum glucose testing, urine tests, chest X-rays and serum prostate-specific antigen testing were also quite common. However, only 6 (1.8%) of the subjects had undergone screening for colorectal cancer (fecal occult blood test or sigmoidoscopy). CONCLUSIONS: A sizeable proportion of health care workers underwent screening procedures that are not recommended or for which there was insufficient evidence of a benefit. Conversely, certain recommended procedures were performed on a small proportion of such workers. These results indicate that the Brazilian National Ministry of Health must develop nationwide evidence-based screening recommendations and disseminate such recommendations among health care professionals in Brazil.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP