Screening for cervical disease in mature women: strategies for improvement

The use of colposcopy for triage in HPV-positive women aged 65 years and older

PURPOSE

Persistent high-risk HPV infection is associated with an elevated risk for prevalent CIN II + despite normal cytology (NILM). Our study aims to evaluate the clinical relevance of a persistent high-risk HPV infection without cytologic changes in women aged ≥ 65 and to determine the role of colposcopy for triage in these cases.

METHODS

211 patients aged ≥ 65 with persistent HPV infection and normal cytology (NILM) who presented for colposcopy at five certified centers between January 2021 and April 2022 were included in the study. Colposcopic findings, HPV subtypes, when available, histology and p16/Ki67 staining were assessed as well as individual risk factors such as smoking and previous HPV-related surgery.

RESULTS

87.7% (185/211) of the included women had a type 3 transformation zone. In 83.4% (176/211), a biopsy was taken [thereof 163 endocervical curettages (ECC)]. In 35/211 women (16.6%), sampling was not possible during colposcopy due to an inaccessible cervix, pain during examination or obliteration of the cervical canal. Out of these, 6 women received a diagnostic excision. CIN II + was detected in 10.6% of all histologies (excisional or biopsy) (20/182). 50% of the women with a CIN II + where HPV 16 positive. Taking only the women diagnosed with CIN III or AIS into account, (n = 12) 75% were HPV 16 positive. Interestingly, 80% of the women with CIN II + had an abnormal cytology when repeatedly taken during colposcopy, vice versa an endocervical lesion was diagnosed in 53% of women with abnormal repeat cytology (27/51).

CONCLUSION

The prevalence of CIN II + in women is ≥ 65 with persistent hr HPV infection but NILM cytology is similar to that in younger women. However, more than 85% of the women have a type 3 transformation zone. Colposcopy is, therefore, not helpful to diagnose the women who need treatment in this age group.

HPV prevalence and HPV-related dysplasia in elderly women

INTRODUCTION

In Sweden, where screening ends at the age of 60, about 30% of the cervical cancer cases occur in women older than 60. The aim of the present study was to investigate the prevalence of HPV and cervical dysplasia in women of 60 years and above.

PATIENTS AND METHODS

From September 2013 until June 2015, 1051 women aged 60-89 years (mean 68 years) were sampled for an HPV test when attending an outpatient gynecology clinic. Women with positive results had a second HPV test and liquid based cytology (LBC), after 3.5 months on average. Those with a positive second HPV test were examined by colposcopy, and biopsy and a sample for LBC was obtained.

RESULTS

The prevalence of HPV was 4.1%, (95%CI 3.0-5.5, n = 43) at the first test, and at the second test 2.6% remained positive (95%CI 1.7-3.8, n = 27). The majority of women positive in both HPV tests, had dysplasia in histology, 81.5% (22/27) (4 CIN 2-0.4%, 18 CIN 1-1.7%). HPV-related dysplasia was found in 2.1%, (95%CI 1.3-3.2, n = 22) of the 1051 women. Four of the 22 women with positive HPV tests also had abnormal cytology, one ASCUS and three CIN 1. No cancer or glandular dysplasia was detected.

CONCLUSION

A significant proportion of elderly women were found to have a persistent cervical HPV infection. Among them there was a high prevalence of CIN diagnosed by histology. The HPV test showed high sensitivity and specificity in detecting CIN in elderly women, while cytology showed extremely low sensitivity.

[Pap Smear after 65 years]

The French recommendations (in favor of stopping cervical cancer screening by cervico-uterine smear from 65 years of age) are logical in the context of organized screening; however, it is not yet generalized in France. The proportion of invasive cervical cancer in the oldest patients is high and these cancers are more evolved and have a more pejorative prognosis. The prevalent infection with high-risk HPV virus remains important in elderly patients: if the HPV infection does not appear to be more risky in the elderly, HPV-induced lesions appear to be more evolving. Unfortunately, pap smear coverage rates are low in the most advanced age groups. Patients without adequate follow-up are exposed to invasive cancer after age 65: all studies insist on the protective effect of two or more normal pap smears between 50 and 65 years that would allow to stop screening. Recent publications in Europe insist, however, on the value of continuing screening beyond the age of 65 in populations that live longer. For the clinician, in France, patients who could benefit from systematic FCU after age 65 could be those: (1) who request it, (2) who have an HPV history, (3) who have not had more than 3 consecutive normal pap smears or (4) who have an associated pathogenic condition. The place of the HPV test deserves to be considered: because of its very high negative predictive value, it could be performed as an exit test or as an alternative test to the pap smear.

Women's intentions to self-collect samples for human papillomavirus testing in an organized cervical cancer screening program

Background

Mounting evidence affirms HPV testing as an effective cervical cancer screening tool, and many organized screening programs are considering adopting it as primary testing. HPV self-collection has comparable sensitivity to clinician collected specimens and is considered a feasible option in hard-to-reach women. We explored women’s intentions to HPV self-collect for cervical cancer screening from a cohort participating in a Canadian randomized controlled cervical cancer screening trial.

Methods

Women aged 25–65 were invited to complete an online survey assessing intentions to be screened with HPV testing instead of the Pap smear. The survey was based in the Theory of Planned Behaviour and questions were included to assess women’s intentions to self-collect for HPV. Demographic characteristics of women who intended to self-collect were compared with those who did not. Demographic and scale variables achieving a p-value <0.1 in the univariate and bivariate analyses were included in the stepwise logistic regression model. The final model was created to predict factors associated with women’s intentions to self-collect an HPV specimen for cervical cancer. Odds ratios were calculated with 95% confidence intervals to identify variables associated with a woman’s intention to self-collect for cervical cancer screening.

Results

The overall survey response rate was 63.8% (981/1538) with 447 (45.6%) reporting they intended to self-collect, versus 534 (54.4%) reporting they did not. In the univariate analysis, women with more than high school education were more likely to self-collect. Women who intended to receive HPV testing versus the Pap smear were 1.94 times as likely to be in favour of self-collection and those who intended to self-collect had significantly higher attitudinal scores towards HPV self-collection. The adjusted odds ratio and 95% confidence interval from the multivariate analysis demonstrated attitude towards self-collection was the only significant variable predicting a woman’s intention to self-collect (OR 1.25; 95% CI: 1.22, 1.29).

Conclusions

The primary predictor of a woman’s intention to HPV self-collect for cervical cancer screening was her attitude towards the procedure. From a program planning perspective, these results indicate that education and awareness may be significant contributing factors to improving acceptance of self-collection and subsequently, improving screening attendance rates.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1060) contains supplementary material, which is available to authorized users.

Low rates of cervical cancer screening among urban immigrants: a population-based study in Ontario, Canada

OBJECTIVE

Women who are immigrants or socioeconomically disadvantaged have been found to have significantly lower cervical cancer screening rates than their peers in Toronto, Ontario, Canada. The objective of this study was to examine rates of appropriate cervical cancer screening among women living in Ontario, Canada, using recent registration with Ontario's universal health insurance plan as an indicator of immigrant status.

METHODS

This retrospective cohort study included 2,273,995 screening-eligible women aged 25 to 69 years, who resided in Ontario's metropolitan areas during the calendar years 2003, 2004, and 2005. A validated algorithm was applied to the Ontario-wide physicians' claims database to determine which women had undergone cervical cancer screening with a Pap test during the 3-year period.

RESULTS

Appropriate cervical cancer screening occurred for 61.1% of women. Despite adjustment for physician contact and pregnancy rates, cervical cancer screening rates were especially low among: women aged 50 to 69 years; women living in low-income areas; and women who had registered with Ontario's universal health insurance plan within the preceding 10 years, a group consisting largely of recent immigrants. Women with all 3 of these characteristics had a screening rate of 31.0% compared with 70.5% among women with none of these characteristics.

CONCLUSION

Within a system of universal health insurance, appropriate cervical cancer screening is significantly lower among women who are older, living in low-income areas, or recent immigrants. Efforts to reduce disparities in cervical cancer screening should focus on women with these characteristics.

Defining a strategy to evaluate cervical cancer prevention and early detection in the era of HPV vaccination

OBJECTIVE

The purpose of this paper is to outline the short-, medium- and long-term requirements of a strategy to evaluate the impact of HPV immunization and to define a framework to facilitate planning and evaluation.

METHOD

This strategy was developed in Ontario from January to August 2008. Literature review was completed to assess existing material relevant to vaccine evaluation, and HPV vaccine specifically. Scientists and epidemiologists within our organization attended meetings to brainstorm and identify key requirements for vaccine evaluation. Other selected internal and external experts were consulted to review preliminary lists of potential indicators and questions for inclusion in an evaluation strategy.

RESULTS

Results are reported in three sections--literature review, proposed evaluation framework and data requirements.

CONCLUSION

The first vaccine evaluation strategy that integrates primary and secondary prevention of cervical cancer is presented. Among women who are neither screened nor immunized, customized interventions will be required to ensure that they are aware of potential risks and benefits. This evaluation strategy may serve as a useful outline for jurisdictions in Canada and elsewhere. This new paradigm of combined primary and secondary intervention will encourage cooperation for effective evaluation of an integrated approach for control of cervical cancer and other HPV-related disease.

Attitudes toward HPV testing: interview findings from a random sample of women in Ontario, Canada

As most women diagnosed with cervical carcinoma have been "inadequately screened," improvements in screening are critical. After abnormal Pap test findings (through liquid-based cytology), residual specimens now can be tested simultaneously for oncogenic types of Human Papilloma virus (HPV). If these "reflex" HPV tests are negative, Pap tests need not be repeated for 12 months. Women with positive oncogenic HPV tests, however, can be referred immediately for colposcopy. There has been concern that "stigma" issues could be associated with positive HPV status (because of its sexual transmission) that might cause women to avoid this reflex HPV testing. We addressed this concern by assessing whether stigma issues surface in relation to HPV testing. We randomly selected 20 women and administered to them semistructured telephone interviews that included responses to a scenario of reflex HPV-DNA testing. Interview transcripts were analyzed qualitatively. Highly limited knowledge levels were found about HPV, but, following education about screening options, there was no rejection of HPV testing. In conclusion, it appears that women favor reflex HPV testing due to its "convenience" and perceptions that it is "the least intrusive option more definitive than Pap testing."

Frequency and outcome of cervical cancer prevention failures in the United States

We measured the frequency and outcome of cervical cancer prevention failures that occurred in the Papanicolaou (Pap) and colposcopy testing phases involving 1,646,580 Pap tests in 4 American hospital systems between January 1, 1998, and December 31, 2004. We defined a screening failure as a 2-step or greater discordant Pap test result and follow-up biopsy diagnosis. A total of 5,278 failures were detected (0.321% of all Pap tests); 48% and 52% of failures occurred in the Pap test and colposcopy phases, respectively. Missed squamous cancers (1 in 187,786 Pap tests), glandular cancers (1 in 19,426 Pap tests), and high-grade lesions (1 in 6,870 Pap tests) constituted 4.1% of all failures. Unnecessary repeated tests or diagnostic delays occurred in 70.8% and 63.9% of failures involving high- and low-grade lesions, respectively. We conclude that cervical cancer prevention practices are remarkably successful in preventing squamous cancers, although a high frequency of failures results in low-impact negative outcomes.

Self-Collected Samples for Testing of Oncogenic Human Papillomavirus: A Systematic Review

BACKGROUND

To investigate the role of self-sampling for human papillomavirus (HPV) testing as an alternative to cervical cancer screening by clinicians (i.e., Papanicolaou [Pap] test).

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane Library, and other sources for evidence related to the efficacy and feasibility of HPV DNA self-collection.

RESULTS

A total of 25 studies were identified. In 22 comparisons across 19 studies, the concordance between samples collected by patients and those obtained by clinicians was reasonably high in the majority of cases. Women in many countries across wide age ranges were successful in collecting samples for HPV DNA testing. In four studies, the quality of the cytology from patient samples was as good as clinician samples, with more than 95% of samples yielding HPV DNA results. The studies that examined acceptability found that women were generally very positive about collecting their own samples, although some concerns were noted. No study evaluated the effect of HPV DNA self-sampling on screening participation rates, early detection, survival, or quality of life.

CONCLUSIONS

Self-sampling for HPV DNA testing is a viable screening option, but there is insufficient evidence to conclude that self-sampling for HPV DNA testing is an alternative to the Pap test. Although HPV DNA testing using self-collected samples holds promise for use in under-resourced areas or for women who are reluctant to participate in Pap testing programs, the evidence supporting it is limited. Further definitive research is needed to provide a solid evidence base to inform the use of self-sampling for HPV DNA testing for the purpose of increasing screening rates, especially in women who are never or seldom screened.

Inadequacy of cervical cancer screening among urban recent immigrants: a population-based study of physician and laboratory claims in Toronto, Canada

OBJECTIVE

In Canada, Pap smears are recommended from 18 to 69. Self-reported socioeconomic gradients in screening have been documented in North America but there have been few direct measures of Pap smear use among immigrants or socially disadvantaged groups. Our purpose was to investigate whether socioedemographic factors are related to cervical cancer screening in Toronto, Canada.

METHOD

Pap smears were identified using fee and laboratory codes in Ontario physician service claims for 3 years (2000-2002 inclusive) for women aged 18-66. Area-level socioeconomic factors were derived from the 2001 census. At the individual level, recent registrants for health coverage, over 80% of whom are expected to be recent immigrants, were identified as women first registering after January 1, 1993.

RESULTS

Among 724,584 women, 55.4% had Pap smears within 3 years. Recent immigration, visible minority, foreign language, low income and low education were all associated with significantly lower area rates. Recent registrants had much lower rates than non-recent registrants (36.9% versus 60.9%).

CONCLUSION

Pap smear rates in Toronto fall below those dictated by evidence-based practice. Recent registrants, a largely immigrant group, have particularly low rates. Efforts to improve coverage need to emphasize women who recently immigrated and those with socioeconomic disadvantage.

Ontario Cervical Cancer Screening Clinical Practice Guidelines

OBJECTIVE

To develop clinical practice guidelines for cervical screening and the primary management of abnormal cytology in Ontario, using an established methodological process.

DATA SOURCES

Primary data sources were relevant articles listed in the Medline (1998 to July 2004), Embase (1998 to July 2004), and Cochrane Library (2004, Issue 2) databases.

STUDY SELECTION

Studies addressing quality or the optimization of cervical screening were considered eligible in the systematic review of the evidence. Specifically, clinical practice guidelines, technology assessments, systematic reviews, and randomized controlled trials were of primary interest. Given the variability of the data, other information sources were considered eligible if there was a demonstrated gap in the published literature.

DATA EXTRACTION

Data were identified and extracted by a methodologist and reviewed by four authors. Results were reviewed and discussed by members of an expert working group consisting of a diverse group of health professionals with expertise in cervical cancer. Data audits were conducted by independent reviewers.

DATA SYNTHESIS

recommendations with evidence ratings were developed through a review of the evidence with expert consensus and were approved by more than 80% of 40 external practitioners who reviewed the document and responded to a standardized survey.

CONCLUSION

The development of comprehensive recommendations on cervical screening in Ontario was feasible using a rigorous methodological process. Recommendations for practice are provided.

Comparison of papanicolaou (Pap) test rates across Ontario and factors associated with cervical screening

BACKGROUND

Cervical cancer remains a significant yet preventable disease despite the widespread availability of Pap test screening, which detects cervical cancer and its precursor lesions. The aims of this study were to: i) estimate and compare age- and hysterectomy-adjusted Pap test rates across the 37 Ontario public health units (PHUs), and ii) explore the association between several factors and Pap test rates (at the ecological level).

METHODS

Cytobase, an Ontario Pap test registry, captures more than 80% of all Pap tests in Ontario. Cytobase was used to determine Pap test rates adjusted for age, hysterectomy and Cytobase coverage for the year 2001. Multiple linear regression analyses were used to evaluate the relationship between Pap test rates and various factors at an ecological level,

RESULTS

Age-, hysterectomy- and Cytobase-adjusted one-year Pap rates ranged from 11.6% to 73.9% among PHUs. The overall rate for Ontario was 40.7%. Multivariate analyses indicated that the presence of a teaching hospital was associated with higher Pap test rates.

CONCLUSION

One-year Pap test rates varied greatly across the 37 public health units in Ontario. Pap test rates determined using Cytobase were lower than self-reported rates obtained from the Canadian Community Health Survey, possibly due to "over-reporting". In general, women were not screened as frequently as recommended by the Ontario Cervical Screening Program. A positive association was observed between Pap test rates and the presence of a teaching hospital. Data quality issues limit the ability to monitor cervical screening. A provincial registry would address these issues.

Diagnoses and outcomes in cervical cancer screening: a population-based study

OBJECTIVE

This study was undertaken to examine routine cervical cancer screening diagnoses and outcomes on an age-specific basis in a US population.

STUDY DESIGN

We conducted an observational cohort study using 1997-2002 health plan administrative and laboratory data for women enrolled at Kaiser Permanente Northwest (Portland, Ore) in 1998.

RESULTS

Across all female enrollees (n=150,052), the annual rate of routine cervical cancer screening was 294.7 per 1,000, with cytologic abnormalities detected at a rate of 14.9 per 1,000. The annual incidence of cervical intraepithelial neoplasia (CIN) 1 was 1.2 per 1,000 with a rate of 1.5 per 1,000 for CIN 2/3. CIN 1 incidence peaked among women aged 20 to 24 years (5.1 per 1,000), with CIN 2/3 rates highest among those 25 to 29 years (8.1 per 1,000). From among 44,493 routine cervical smears, results were normal for 94.5%, with abnormal diagnoses of atypical squamous cells (3.3%), atypical glandular cells (0.2%), low-grade squamous intraepithelial lesion (1.2%), high-grade squamous intraepithelial lesion (0.3%), and inconclusive/inadequate (0.5%). Of women with abnormal routine smears, CIN or cancer was detected on follow-up in 19.4% of cases, 51.5% were found to have had a false-positive smear, and 29.0% incomplete follow-up as defined by published management guidelines.

CONCLUSION

These are the first comprehensive age-specific estimates of routine cervical cancer screening diagnoses and outcomes to be reported within a US general healthcare setting. Overall, 5% of routinely screened women were found to have an abnormal cervical smear with an annual incidence of CIN across all female enrollees of 2.7 per 1000.

The Dutch CISOE-A framework for cytology reporting increases efficacy of screening upon standardisation since 1996

AIM

To describe the effect of introducing the CISOE-A framework for reporting cervical cytology results, including changes in repeat and referral advice in the Netherlands, on the efficacy of the screening programme. Changes in the distribution of cytological results, the detection rate of cervical intraepithelial neoplasia (CIN) lesions, and the detection rate of squamous cervical carcinoma are reported.

METHODS

The results of all gynaecology cytological and histological examinations, as registered in the nationwide database for histopathology and cytopathology (PALGA) from 1990 to 2000, were retrieved from seven laboratories in the greater Amsterdam area.

RESULTS

After the introduction of the CISOE-A classification, cytological results with equivocal diagnoses decreased significantly from 11.3% to 2.6%, without an increase in the percentages of moderate dyskaryosis or worse. During the study period, the detection rate of histologically diagnosed high grade CIN lesions increased significantly from 4.1 to 6.4/1000 smears, whereas there was no change in the detection rates of low grade lesions or invasive cervical cancer.

CONCLUSIONS

The introduction of the new CISOE-A classification system resulted in a substantial decrease of equivocal results and repeat recommendations, without a decrease in the detection rate of high grade lesions, making the screening programme more efficacious.