Foreword: Convening an international conference on cervical cancer

In 1999, representatives of the National Cancer Institute, The Johns Hopkins Medical Institutions, and The University of Texas M. D. Anderson Cancer Center began discussions concerning sponsoring yearly conferences on cervical cancer. The purpose of these meetings would be to review current knowledge in various aspects of cervical cancer, including epidemiology, prevention, screening, treatment, and quality of life, and make recommendations for further research. The program would cover both preinvasive and invasive cervical disease and span the developed and developing worlds. We also wanted to involve young investigators to encourage their ongoing participation in cervical cancer research.

The First International Conference on Cervical Cancer convened in Baltimore, Maryland between April 6–8, 2001, and the second in the series followed 1 year later in Houston between April 11–14, 2002. One of the cosponsors during the first year, the Alliance for Cervical Cancer Prevention, also took the opportunity to hold the Consultative Forum on Cervical Cancer Prevention in Low-Resource Settings on April 5, 2001, in Baltimore. Because these two meetings were thus held back-to-back (and in the same hotel), we were able to strengthen the international representation at our conference. We are particularly grateful to the Alliance for Cervical Cancer Prevention for its cooperation. We also are grateful for the help of the cosponsoring organizations in publicizing the conference and suggesting speakers. In addition, we thank our federal partners for their support in planning and underwriting the costs of the conference, as well as the corporate sponsors for their unrestricted educational grants, which helped make the conference possible.

The first day of the initial conference covered epidemiology and cancer biology, the second day discussed screening, and the third day was an examination of health-related quality of life. The expanded second conference included topics concerning decision science, behavioral science, nursing, chemoprevention and biomarkers, imaging the cervix and innovations in imaging technology, and innovations in the biologic understanding of cervical cancer. We are grateful to the speakers and the discussants for their thoughtful presentations. A brief review follows of selected questions raised by the presentations.

Human Papillomavirus Biology

Although we have made major strides in understanding the biology of the human papillomavirus (HPV), we still do not understand the impact cofactors may have on the development of neoplasia. Do some individuals have an inherited predisposition toward developing HPV-associated disease? How do host and viral genetic polymorphisms affect the development of cervical neoplasia ? Does HPV integration of the host genome cause both random and specific chromosomal changes ? How do these chromosomal alterations change host gene expression ? How does HPV escape immune surveillance? What is the role of local inflammation, of immunosuppression, of exogenous and endogenous hormones, of male factors, of tobacco? What causes spontaneous regression of HPV disease? How can we reduce the risk of HPV transmission with sexual contact? We need more and better models for cervical cancer to explore these issues and to identify effective prevention and treatment strategies.

Developing Countries

Participants emphasized the importance of developing sustainable, simple screening programs that would be acceptable to women. Adding more women providers was considered to be critical, as was obtaining specific training in oncologic care for patients diagnosed with invasive cancer. We need definitive studies comparing visual inspection, HPV testing, cytology, colposcopy, and other techniques, in terms of cost-effectiveness in decreasing cervical cancer incidence and mortality. When might a “see-and-treat” approach be most useful? We also need to know the efficacy of treatment for preinvasive disease among women who are positive for the human immunodeficiency virus (HIV), as well as the optimal surveillance after initial screening or initial treatment in both HIV-negative and HIV-positive individuals.

Developed Countries

Participants in this meeting stressed the importance of defining the roles of HPV testing and liquid-based cytology in standard screening programs. Can automation lower the incidence of cervical cancer and reduce the cost of Papanicolaou smear screening ? We need to learn how to bring women who currently are not undergoing screening into screening. Older women, particularly those without insurance, those who are poor, and those who are members of minority ethnic groups, are less likely to be screened. How do we increase risk-appropriate screening ? In addition, we need to learn how to ensure that all health care providers routinely screen women at risk for cervical disease. The development of culturally competent educational and screening programs is critical.

Vaccine Development

Understanding local immunity at the level of the cervical mucosa emerged as an important research issue. The development and validation of surrogate endpoint biomarkers also was considered key. We also need to evaluate different vaccine strategies, both singly and in combination, to identify the optimal agents, doses, schedules, and routes of administration. Can we prevent transmission of HPV ? Can we prevent the development of neoplasia among women exposed to HPV ? Can we treat invasive cervical cancer with an immunologic approach?

Holistic Care for Women with Cancer

Enhancing quality of life for women with cervical cancer requires strengthening social and psychologic support, a strong emphasis on patient education, and holistic treatment focused on the whole person rather than just the disease. Complementary and alternative medicines often are used; their use should be optimized. We need to identify and implement culturally sensitive, effective ways to maintain intimacy and sexuality in women with cervical cancer.

Treatment and Quality of Life

Our understanding of the late effects of radiation, chemoradiation, and surgery for cervical cancer is limited. Might radioprotectors be able to preserve normal tissue and function ? We need to understand how genetic and environmental factors influence the risk for treatment-related complications. Can we move toward less radical surgery in women with early-stage cervical cancer ? What surgical approaches can best preserve bladder, bowel, and sexual function ? How can we improve quality of life for survivors ? What are the appropriate indications and limitations for radical vaginal trachelectomy ? When is conization considered adequate treatment for women with Stage IA1 disease? Can we decrease the risk of short-term and long-term complications by developing centers of excellence for the treatment and rehabilitation of women with cervical cancer?

These and other questions offer many opportunities for investigation and a glimpse of the possibilities for improving screening, treatment, and rehabilitative care in the future.