Development of a Risk Index for Prediction of Abnormal Pap Test Results in Serbia

  • Vukovic, Dejana (University of Belgrade, Faculty of Medicine, Institute for Social Medicine) ;
  • Antic, Ljiljana (College of Health Studies in Cuprija) ;
  • Vasiljevic, Mladenko (University of Belgrade, Faculty of Medicine, University Clinic of Gynaecology and Obstetrics Narodni Front) ;
  • Antic, Dragan (College of Health Studies in Cuprija) ;
  • Matejic, Bojana (University of Belgrade, Faculty of Medicine, Institute for Social Medicine)
  • Published : 2015.04.29


Background: Serbia is one of the countries with highest incidence and mortality rates for cervical cancer in Central and South Eastern Europe. Introducing a risk index could provide a powerful means for targeting groups at high likelihood of having an abnormal cervical smear and increase efficiency of screening. The aim of the present study was to create and assess validity ofa index for prediction of an abnormal Pap test result. Materials and Methods: The study population was drawn from patients attending Departments for Women's Health in two primary health care centers in Serbia. Out of 525 respondents 350 were randomly selected and data obtained from them were used as the index creation dataset. Data obtained from the remaining 175 were used as an index validation data set. Results: Age at first intercourse under 18, more than 4 sexual partners, history of STD and multiparity were attributed statistical weights 16, 15, 14 and 13, respectively. The distribution of index scores in index-creation data set showed that most respondents had a score 0 (54.9%). In the index-creation dataset mean index score was 10.3 (SD-13.8), and in the validation dataset the mean was 9.1 (SD=13.2). Conclusions: The advantage of such scoring system is that it is simple, consisting of only four elements, so it could be applied to identify women with high risk for cervical cancer that would be referred for further examination.


Cervical cancer;risk;index score;pap test;Serbia


  1. Al-Daraji WI, Smith JH (2009). Infection and cervical neoplasia:facts and fiction. Int J Clin Exp Pathol, 2, 48-64.
  2. Antic LG, Vukovic DS, Vasiljevic MD, Antic DZ, Aleksopulos HG (2014). Differences in risk factors for cervical dysplasia with the applied diagnostic method in Serbia. Asian Pac J Cancer Prev, 15, 6697-701.
  3. Castellsague X, Muñoz N (2003). Chapter 3: Cofactors in human papillomavirus carcinogenesis--role of parity, oral contraceptives, and tobacco smoking. J Natl Cancer Inst Monogr, 31, 20-8.
  4. Cole J, Logan TK, Shannon L (2007). Risky sexual behavior among women with protective orders against violent male partners. AIDS Behav, 11, 103-12.
  5. Collins S, Rollason TP, Young LS, Woodman CB (2010). Cigarette smoking is an independent risk factor for cervical intraepithelial neoplasia in young women: a longitudinal study. Eur J Cancer, 46, 405-11.
  6. Conti M, Agarossi A, Parazzini F, Muggiasca ML, Boschini A, Negri E, et al (1993). HPV, HIV infection, and risk of cervical intraepithelial neoplasia in former intravenous drug abusers. Gynecol Oncol, 49, 344-8.
  7. Corral F, Cueva P, Yepez J, Montes E (1996). Limited education as a risk factor in cervical cancer. Bull Pan Am Health Organ, 30, 322-329.
  8. International Collaboration of Epidemiological Studies of Cervical Cancer (2006). Carcinoma of the cervix and tobacco smoking: collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. Int J Cancer, 118, 1481-95.
  9. International Collaboration of Epidemiological Studies of Cervical Cancer (2006). Cervical carcinoma and reproductive factors: collaborative reanalysis of individual data on 16,563 women with cervical carcinoma and 33,542 women without cervical carcinoma from 25 epidemiological studies. Int J Cancer, 119, 1108-24.
  10. International Collaboration of Epidemiological Studies of Cervical Cancer (2007). Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Int J Cancer, 120, 885-91.
  11. International Collaboration of Epidemiological Studies of Cervical Cancer (2009). Cervical carcinoma and sexual behavior: collaborative reanalysis of individual data on 15,461 women with cervical carcinoma and 29,164 women without cervical carcinoma from 21 epidemiological studies. Cancer Epidemiol Biomarkers Prev, 18, 1060-9.
  12. Kesic V, Poljak M, Rogovskaya S (2012). Cervical cancer burden and prevention activities in Europe. Cancer Epidemiol Biomarkers Prev, 21, 1423-33.
  13. Kjellberg L, Hallmans G, Ahren AM, et al (2000). Smoking, diet, pregnancy and oral contraceptive use as risk factors for cervical intra-epithelial neoplasia in relation to human papillomavirus infection. Br J Cancer, 82, 1332-8.
  14. Lofters AK, Moineddin R, Hwang SW, Glazier RH (2013). Does social disadvantage affect the validity of self-report for cervical cancer screening? Int J Womens Health, 5, 29-33.
  15. Maree JE, Wright SC, Makua TP (2011). Men's lack of knowledge adds to the cervical cancer burden in South Africa. Eur J Cancer Care (Engl), 20, 662-8.
  16. Nelson W, Moser RP, Gaffey A, Waldron W (2009). Adherence to cervical cancer screening guidelines for U.S. women aged 25-64: data from the 2005 Health Information National Trends Survey (HINTS). J Womens Health, 18, 1759-68.
  17. Pacarada M, Lulaj S, Kongjeli G, Kongjeli N, Qavdarbasha H (2010). Factors associated with pathologic colposcopic and cytologic changes in 500 clinically asymptomatic women. Int J Gynaecol Obstet, 108, 7-11.
  18. Patil V, Wahab SN, Zodpey S, Vasudeo ND (2006). Development and validation of risk scoring system for prediction of cancer cervix. Indian J Public Health, 1, 38-43.
  19. Petry KU, Luyten A, Justus A, et al (2013). Prevalence of high-risk HPV types and associated genital diseases in women born in 1988/89 or 1983/84--results of WOLVES, a population-based epidemiological study in Wolfsburg, Germany, 13, 135.
  20. Raychaudhuri S, Mandal S (2012). Socio-demographic and behavioural risk factors for cervical cancer and knowledge, attitude and practice in rural and urban areas of North Bengal, India. Asian Pac J Cancer Prev, 13, 1093-6.
  21. Reich O (2005). Is early first intercourse a risk factor for cervical cancer? Gynakol Geburtshilfiche Rundsch, 45, 251-6.
  22. Reiter P, Katz M, Ferketich A, et al (2009). Measuring cervical cancer risk: development and validation of the CARE risky sexual behavior index. Cancer Causes Control, 20, 1865-71.
  23. Remschmidt C, Kaufmann AM, Hagemann I, et al (2013). Risk factors for cervical human papillomavirus infection and high-grade intraepithelial lesion in women aged 20 to 31 years in Germany. Int J Gynecol Cancer, 23, 519-26.
  24. Schoueri-Mychasiw N, McDonald PW (2013). Factors associated with underscreening for cervical cancer among women in Canada. Asian Pac J Cancer Prev, 14, 6445-50.
  25. Schroder KE, Carey MP, Vanable PA (2003).Methodological challenges in research on sexual risk behavior: II. Accuracy of self-reports. Ann Behav Med, 26, 104-23.
  26. Sherris J, Wittet S, Kleine A, et al (2009). Evidence-based, alternative cervical cancer screening approaches in lowresource settings. Int Perspect Sex Reprod Health, 35, 147-54.
  27. Smith JS, Green J, Berrington de Gonzalez A, et al (2003). Cervical cancer and use of hormonal contraceptives: a systematic review. Lancet, 5, 1159-67.
  28. Stone KM, Zaidi A, Rosero-Bixby L, et al (1995). Sexual behavior, sexually transmitted diseases, and risk of cervical cancer. Epidemiol, 6, 409-14.
  29. Uysal A, Birsel A (2009). Knowledge about cervical cancer risk factors and pap testing behavior among Turkish women. Asian Pac J Cancer Prev, 10, 345-50.
  30. Vrdoljak E, Wojtkiewicz MZ, Bodoky G, et al (2011). Cancer epidemiology in Central and South Eastern European Countries. Croat Med J, 52, 478-87.
  31. Wilkinson CE, Peters TJ, Stott NC, Harvey IM (1994). Prospective evaluation of a risk scoring system for cervical neoplasia in primary care. Br J Gen Pract, 44, 341-4.

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