Improving cervical cancer screening attendance in Finland

Effectiveness of self-sampling human papillomavirus test on precancer detection and screening uptake in Japan: The ACCESS randomized controlled trial

Japan is lagging in cervical cancer prevention. The effectiveness of a self-sampling human papillomavirus (HPV) test, a possible measure to overcome this situation, has not yet been evaluated. A randomized controlled trial was performed to evaluate the effectiveness of a self-sampling HPV test on detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and screening uptake. Women between 30 and 58 years old who did not participate in the cervical cancer screening program for ≥3 years were eligible and assigned to the intervention group (cytology or self-sampling HPV test) or control group (cytology). Participants assigned to the intervention group were sent a self-sampling kit according to their ordering (opt-in strategy). A total of 7337 and 7772 women were assigned to the intervention and control groups, respectively. Screening uptake in the intervention group was significantly higher than that in the control group (20.0% vs. 6.4%; risk ratio: 3.10; 95% confidence interval [CI]: 2.82, 3.42). The compliance rate with cytology triage for HPV-positive women was 46.8% (95% CI: 35.5%, 58.4%). CIN2+ was detected in five and four participants in the intervention and control groups, respectively; there was no difference for intention-to-screen analysis (risk ratio: 1.32; 95% CI: 0.36, 4.93). Self-sampling of HPV test increased screening uptake; however, no difference was observed in the detection of CIN2+, probably due to the low compliance rate for cytology triage in HPV-positive women. Efforts to increase cytology triage are essential to maximize precancer detections.

Social factors and age play a significant role in cervical cancer and advanced-stage disease among Danish women

BACKGROUND

For cervical cancer (CC), the implementation of preventive strategies has the potential to make cervical cancer occurrence and death largely avoidable. To better understand the factors possibly responsible for cervical cancer, we aimed to examine possible differences in age and social parameters as well as screening status between women with low- or high-stage cervical cancer and matched controls.

METHODS

Through the Danish Cancer Registry (DCR), women diagnosed with cervical cancer in Denmark between 1987 and 2016 were included. These were age- and residence-matched in a 1:5 ratio with controls from the general female population. The study population was sub grouped into a low-stage subpopulation with women with early-stage cervical cancer and matched controls and a high-stage subpopulation with women with late-stage cervical cancer and matched controls. Age and social parameters were compared within the subpopulations as well as between low- and high-stage cases. For part of the study population, screening attendance was examined to compare differences in adherence.

RESULTS

Overall, we found that the risk of cervical cancer is significantly increased in socially disadvantaged women and not least non-attenders in screening. Interestingly, the high-stage subpopulation was significantly older than the low-stage subpopulation (p < 0.001), and when examining the impact of age further, we found that for cervical cancer cases, the risk of having low-stage disease decreases significantly with increasing age, whereas the risk of having high-stage disease increases significantly with increasing age. In the screening cohort, significantly less cases than controls were attenders in screening with the most pronounced differences seen in the old subpopulation (women aged 50-64 years) and in the high-stage subpopulation (p-values all < 0.001). Interestingly, when examining the risk of CC for attenders and non-attenders, we demonstrated that many social parameters continue to influence the risk of cervical cancer, even in women attending screening.

CONCLUSIONS

Older women, socially disadvantaged women, and non-attenders in screening are particularly vulnerable in terms of developing cervical cancer, especially high-stage disease. Therefore, improvements in the participating rate in screening as well as a revision of the current screening guidelines are needed.

Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis

Organized cervical cancer screening programs to promote the early identification of precancerous lesions have proven to be effective in decreasing the burden associated with cervical cancer, but knowledge regarding screening adherence among migrant women compared to that of native women has not been summarized. A systematic search of the literature on PubMed, Scopus and Embase led to the identification of 772 papers that were published up to July 2022 and reported population-based data regarding adherence to cervical screening. The screening participation rates among migrant women, compared to native women, were pooled using a random-effects meta-analysis. A total of 18 papers were included in the review, with most of them being conducted in Europe (83.3%). Overall, migrants showed a significantly lower participation rate compared to native women (OR for screening adherence: 0.54, 95% CI = 0.42-0.70). This discrepancy was especially evident for migrant women from North Africa and Sub-Saharan Africa (OR = 0.47, 95% CI = 0.35-0.63, and OR = 0.35, 95% CI = 0.24-0.49, respectively). The results of this systematic review emphasize the importance of increasing cervical cancer screening adherence among migrant women. A significant heterogeneity in screening adherence was observed based on the country of origin. Interventions aimed at reducing the disparities in screening participation should specifically consider how to improve the recruitment of migrant women.

Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials

Objectives

A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples.

Methods

The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools.

Results

One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely.

Conclusions

Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.

Human papillomavirus self-sampling with mRNA testing benefits routine screening

High risk human papillomavirus (hrHPV) based screening provides the possibility of vaginal self-sampling as a tool to increase screening attendance. In order to evaluate the impact and feasibility of opt-in self-sampling in the Finnish setting, we invited a randomized population of 5350 women not attending screening after age group invitation or after reminder, to attend HPV self-sampling-based screening in the autumn of 2018 in Helsinki. Out of those, 1282 (24.0%) expressed their interest and ordered the sampling package. Eventually 787 women (14.7% of the total invited population) took part in screening, 770 women by providing a vaginal sample within 2 months from invitation and 17 by providing a pap smear in the laboratory. Self-taken samples were collected in Aptima Multitest vials and tested using the Aptima HPV mRNA assay. A high proportion, 158/770 (20.5%) of the samples were positive in the Aptima HPV assay. One hundred and forty-one samples were further submitted to Aptima HPV Genotyping and extended genotyping by a Luminex based assay. Of those, 23 samples (16.3%) were HPV 16 positive and 7 (5.0%) were positive for HPV 18/45; extended genotyping revealed multiple high-risk and low-risk HPV genotypes. At follow-up seven cases of high-grade squamous intraepithelial lesion (HSIL) were diagnosed, which represents 4.4% of HPV positive women and 0.9% of screened women, whereas the rate was 0.5% in routine screening. Our findings suggest that self-sampling with HPV mRNA testing is a feasible approach to improve screening efficacy in a high-risk population among original nonattendees.

Effect of Patient Characteristics on Uptake of Screening Using a Mailed Human Papillomavirus Self-sampling Kit: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Mailing human papillomavirus (HPV) self-sampling kits increases cervical cancer screening participation, but effects may differ across subpopulations. Subpopulation data can inform US health care system implementation.

OBJECTIVE

To identify patient characteristics that modify effectiveness of a mailed kit intervention at increasing screening.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of data from the Home-Based Options to Make Cervical Cancer Screening Easy (HOME) randomized clinical trial conducted from 2014 to 2018 at Kaiser Permanente Washington. Data analysis was performed from March 2018 to May 2022. Individuals aged 30 to 64 years with female sex, health plan enrollment longer than 3 years and 5 months, a current primary care clinician, and no Papanicolaou test within the prior 3 years and 5 months were identified through electronic medical records and randomized (1:1) to the control or intervention group.

INTERVENTIONS

The control group received usual care Papanicolaou screening reminders and outreach. The intervention group received usual care plus an unsolicited mailed HPV self-sampling kit.

MAIN OUTCOMES AND MEASURES

Screening uptake was captured within 6 months after randomization. Baseline patient characteristics (age, race, ethnicity, travel time to clinic, income, body mass index, tobacco use, health plan enrollment duration, time since last Papanicolaou test, mammography, comorbidities, and colorectal cancer screening adherence) were extracted from the electronic medical record.

RESULTS

Of 19 734 individuals (mean [SD] age, 50.1 [9.5] years; 14 129 [71.6%] White), 9843 were randomized to the intervention group, and 9891 were randomized to the control group. Screening uptake was 26.3% (2592 of 9843 individuals) in the intervention group vs 17.4% (1719 of 9891 individuals) in the control group (relative risk [RR], 1.51; 95% CI, 1.43-1.60). Although absolute differences in uptake by group varied little by screening history, relative effects were greater with longer vs shorter time since last Papanicolaou test (no prior Papanicolaou test: RRs, 1.85-3.25; ≥10 years: RR, 2.78; 5-10 years: RRs, 1.69-1.86; <5 years: RRs 1.29-1.37). Relative effects were greater in participants overdue (RR, 2.03; 95% CI, 1.73-2.38) vs up-to-date with mammography (RR, 1.53; 95% CI, 1.41-1.67), although absolute difference was greater in the up-to-date group. Differences by age were not significant, with RRs of 1.33 to 1.48 across 5-year age groups in participants 30 to 54, vs 1.60 (95% CI, 1.40-1.82) in participants 55 to 59 and 1.77 (95% CI, 1.56-2.01) in participants 60 to 64 years. Among those mailed kits, there were differences in kit use vs in-clinic screening by age, race, plan enrollment duration, underscreening duration, and colorectal cancer screening adherence.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, clinically important improvements in screening uptake were observed for all subgroups. Differences in magnitude of intervention effect and kit use highlighted opportunities to optimize HPV self-sampling for priority groups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02005510.

Implementation of a self-sampling HPV test for non-responders to cervical cancer screening in Japan: secondary analysis of the ACCESS trial

A self-sampling human papillomavirus (HPV) test could improve the morbidity and mortality of cervical cancer in Japan. However, its effectiveness and feasibility have not been demonstrated sufficiently. Hence, we launched a randomized controlled trial, which is ongoing, and report the results of a secondary analysis. To ensure autonomous participation with a minimum selection bias, opt-out consent was obtained from women who met the inclusion criteria, and written consent was obtained from those who underwent a self-sampling test. The number of women who met the inclusion criteria was 20,555; 4283 and 1138 opted out before and after the assignment, respectively. Of the 7340 women in the self-sampling arm, 1372 (18.7%) ordered and 1196 (16.3%) underwent the test. Younger women in their 30 s and 40 s tended to undertake the test more frequently than older women in their 50 s (P for trend < 0.001). Invalid HPV test results were rare (1.3%), and neither adverse events nor serious complaints were reported. Despite adopting the opt-out procedure, more women than expected declined to participate, suggesting the need for a waiver of consent or assignment before consent to reduce selection bias. A self-sampling HPV test can be implemented in Japan and would be more accessible to young women, the predominant group affected by cervical cancer.

Direct mail from primary care and targeted recruitment strategies achieved a representative uptake of prostate cancer screening

OBJECTIVES

Prostate cancer screening studies has previously not been able to reflect a diverse group of participants. We evaluated a range of recruitment strategies and their ability to recruit from the Black population and areas of deprivation.

STUDY DESIGN AND SETTINGS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 participants conducted at seven UK primary care practices and two imaging centres. All participants underwent screening with a PSA test, MRI and transrectal ultrasound. A number of recruitment strategies were embedded including direct mail, media campaigns and a targeted recruitment strategy to increase participation among harder-to-reach groups.

RESULTS

1,316 expressions of interest in total were received (20^th September 2018 to 15th May 2019). The direct mail strategy generated 317 expressions of interest from 1707 invitation letters. 387 expressions of interest were received following the targeted strategy and 612 from media campaigns. The recruitment target was met 19 months ahead of schedule. Of 411 participants, ethnicity was White (38.0%), Black (32.4%), Asian (23.0%) and Other/Mixed (4.4%) ethnic groups. This higher recruitment of black men was driven by the targeted recruitment strategy. A comparison of recruitment methods showed marked differences between ethnicities recruited (p<0.001). The proportion of black participants recruited by direct mail (8%) was similar to the prevalence of black local population (9%) whereas targeted recruitment was 88% (115) and media recruitment 1.7% (1). The Index of Multiple Deprivation (IMD) distribution was similar to the local population with marginal higher recruitment from more deprived areas; proportion increasing from 26% to 40% from least to most deprived IMD quintiles (Quintiles 4/5 vs. 1/2). Direct mail recruited a close-to-normal distribution for deprivation with targeted recruitment trending towards recruiting from most deprived areas.

CONCLUSIONS

Direct mail and targeted strategies designed to engage a diverse population can achieve a representative uptake from black participants and those from a lower socioeconomic group.

Examining Primary Care Physicians' Intention to Perform Cervical Cancer Screening Services Using a Theory of Planned Behavior: A Structural Equation Modeling Approach

Background

Promoting cervical cancer screening (CCS) is undoubtedly effective in combating severe public health problems in developing countries, but there are challenges to its implementation. Understanding the factors influencing primary care physicians' intentions to provide CCSs to rural women is crucial for the future implementation of screening programs. The aim of this study was to assess the intentions of primary care physicians to provide cervical cancer screening services (CCSSs) to rural women and their determinants.

Methods

This cross-sectional study included 1,308 primary care physicians in rural primary health care, and the data collection tool was developed based on the theory of planned behavior (TPB), which included demographic characteristics, the basic constructs of TPB, and the degree of knowledge of CCSSs as an extended variable of the TPB model. Structural equation modeling was used to analyze the relationships between each factor.

Results

Pathway analysis found that TPB is an appropriate theoretical basis for predicting primary care physicians' intent to provide CCSSs (χ2/df = 2.234 &lt; 3, RMSEA = 0.035, and SRMR = 0.034). Meanwhile, the structural equation model showed that attitude (β = 0.251, p &lt; 0.001), subjective norm (β = 0.311, p &lt; 0.001), perceived behavioral control (β = 0.162, p &lt; 0.001), and knowledge level (β = 0.152, p &lt; 0.01) positively predicted primary care physicians' intention to provide CCSSs.

Conclusions

TPB model, with the addition of knowledge, was useful in predicting primary care physicians' intention to provide CCSSs for rural Chinese women. The findings of this study provide a reference for the government and hospitals to develop strategies to improve the intent of primary care physicians to provide CCSSs.

Health inequalities among Russian-born immigrant women in Finland: longitudinal analysis on cervical cancer incidence and participation to screening

Research has documented both lower and higher cancer incidence among migrants. Evidence among the large Russian-born migrant population, however, is scarce. We examined cervical cancer incidence and screening participation among Russian-born immigrant women in Finland, a country with complete cancer registration and universal public health care including organized cancer screening. Our study population included all the women that resided in Finland during 1970–2017 and was formed linking individual-level data from four nationwide registries. The linked data sets on cancer and cancer screening were analysed separately using different statistical models. Russian-born immigrant women had increased (+62%) incidence of cervical cancer compared to the general Finnish female population, and they participated in cervical cancer screening slightly less than other women. Our findings showed no consistent transition pattern in cancer incidence or screening participation rate with duration of stay. Potential explanations for the observed differences include institutional and behavioural factors. Cervical cancer is one of the most preventable cancers, and cancer screening can both prevent and reduce incidence and mortality of cervical cancer. Efforts should be made to encourage migrant populations to participate in cervical screening.

Cervical, vaginal and vulvar cancer incidence and survival trends in Denmark, Finland, Norway and Sweden with implications to treatment

Background

Incidence of cervical cancer has been reduced by organized screening while for vaginal and vulvar cancers no systematic screening has been implemented. All these cancers are associated with human papilloma virus (HPV) infection. We wanted to analyze incidence trends and relative survival in these cancers with specific questions about the possible covariation of incidence, survival changes coinciding with incidence changes and the role of treatment in survival. We used nationwide cancer registry data for Denmark (DK), Finland (FI), Norway (NO) and Sweden (SE) to address these questions.

Methods

We use the NORDCAN database for the analyses: incidence data were available from 1943 in DK, 1953 in FI and NO and 1960 in SE, through 2016. Survival data were available from 1967 through 2016. World standard population was used in age standardization.

Results

In each country the incidence of cervical cancer declined subsequent to rolling out of screening activities. The attained plateau incidence was lowest at 4/100,000 in FI and highest at 10/100,000 in DK and NO. The incidence of vaginal and vulvar cancer remained relatively constant at about 2/100,000. Relative 1-year survival in cervical cancer improved in all countries from low 80%s to high 80%s in the 50-year period, and 5-year survival improved also but at 20% units lower level. Survival gains were found only in patients diagnosed before age 60 years. Survival in vaginal and vulvar cancer followed the same patterns but at a few % units lower level.

Conclusion

Cervical cancer screening appeared to have reached its limits in the Nordic countries by year 2000. Novel treatments, such as immunotherapy, would be needed to improve survival until HPV vaccination will reach population coverage and boost the global fight against these cancers.

Cervical testing beyond the screening target age - A register-based cohort study from Finland

OBJECTIVE

It has been proposed that cervical cancer screening should be continued in women with previous abnormal results or irregular attendance. We examined the coverage and factors that might influence cervical testing beyond the age range of the organized cervical screening programme in Finland. The national programme invites women in every five years least until the age of 60. After the stopping age, only opportunistic service is available.

METHODS

Data on cervical testing were collected from the Mass Screening Registry and providers of opportunistic Pap/HPV-testing and were linked with information on socio-economic variables. The study included 373,353 women who had at least one invitation to the national screening programme between ages 50-60 years, and who were aged 65-74 years in the follow-up period 2006-2016. Multivariable binomial regression models were conducted to determine associations.

RESULTS

Altogether 33% of the study population had been tested at least once at ages 65-74 years. Previous regular screening attendance (adjRR 1.70; 95% CI 1.67-1.73) and earlier abnormal results (adjRR 2.08; 95% CI 2.04-2.12) were most clearly related to higher testing adherence at older age. Other factors related to higher testing adherence were urban area of residence, domestic mother tongue, high education level, and high socio-economic status.

CONCLUSION

Testing at older age was frequent with normal results, whereas only a small proportion of women with earlier abnormal results or irregular attendance were tested. The upper age limit of the national programme should be raised to 65 years, and the invitations thereafter should be targeted to selected high-risk groups.

DNA Recovery Using Ethanol-Based Liquid Medium from FTA Card-Stored Samples for HPV Detection

INTRODUCTION

Alternative methods of dry storage and transportation may be a viable alternative to the use of liquid storage medium for cervical samples, especially for screening programs in places with few resources.

OBJECTIVE

The objective of this study is to verify the viability and efficacy of human papillomavirus DNA (HPV-DNA) detection in cervical cell samples collected and stored on a Flinders Technology Associates (FTA) card (Whatman Indicating FTA® Elute Micro Card) and subsequently recovered in ethanol-based liquid medium and to compare the results to those obtained using samples stored directly in ethanol-based liquid medium.

STUDY DESIGN

Thirty-four women submitted to ETZ (excision of the transformation zone of the cervix) were included in this study. Before ETZ, 2 samples of exfoliated cervical cells were collected from each woman by a doctor and stored in ethanol-based liquid medium and on an FTA card. DNA recovery from FTA samples was performed using ethanol-based liquid medium. Detection of HPV-DNA in the samples was performed using the Cobas® 4800 HPV Test Platform.

RESULTS AND CONCLUSIONS

The HPV-DNA detection positivity rates were 70.6% for the samples collected directly in liquid medium and 64.7% for the samples stored on the FTA card, with high detection accuracy in the DNA samples recovered from the FTA card (area under the curve = 0.958; 95% confidence interval = 0.890-1.000). The concordance between the results obtained using the 2 storage media was 94.1% (Kappa = 0.866). These preliminary results suggest that collection of cervical material on an FTA card may be an alternative to storage in liquid medium since the liquid medium has some limitations. In addition, DNA recovery from the card using ethanol-based liquid medium streamlines the workflow in the laboratory and reduces the cost associated with reagents, thereby facilitating access to the HPV test in places with few resources and potentially improving cervical cancer screening.

Investigating the decrease in participation in the Dutch cervical cancer screening programme: The role of personal and organisational characteristics

Declining attendance in the Dutch cervical cancer screening programme was recently observed, coinciding with preparations for implementing primary hrHPV-based screening, which was implemented in January 2017. We aimed to investigate which factors were related to decreased attendance. We conducted a population-based cohort study including all women aged 30 to 60 years who were eligible for screening between 2014 and 2018. Attendance was defined as participation in the screening programme within 15 months of the start of the invitation-eligible year. We used data from the Dutch pathology archive (PALGA) linked with data from Statistics Netherlands to investigate population characteristics (position in the household, household income, socio-economic status, number of people in the household, migration background, age) and data from the five Dutch screening organisations (SO) to investigate the effect of cessing self-inviting GP's ('inviting organisation'). SO's were termed SO 1 to 5. Higher attendance rates were observed in women who were employed (60.8%), married (62.9%), Dutch (61.2%), in the highest income bracket (63.4%), living in households with four persons (65.3%) and women who were invited by their GP (69.8%). Differences in personal characteristics did not explain the decline in attendance rates. By adjusting for whether the GP or the SO sent the invitation, the differences in attendance rates between 2014 and 2015 and 2016 and between 2014 and 2015 and 2017-2018 were explained in some screening organisations. Removing the possibility for GPs to send invitations explains some of the decline in participation, although this did not account for the total change in attendance.

Adherence to international recommendations in the governance and organisation of Nordic cervical cancer screening programmes

INTRODUCTION

Screening has been the primary reason for the decline in the incidence and mortality of cervical cancer in the Nordic countries since the beginning of screening in the 1960s. Recently, the incidence of cervical cancer has increased in the Nordic countries indicating the need to look closely at possibilities for further improvement in screening. This article provides an overview of cervical cancer screening programmes in the Nordic countries and whether the programmes adhere to international recommendations.

MATERIALS AND METHODS

Relevant and unambiguous screening recommendations were extracted from applicable literature and classified into legal framework, governance, organisation, and monitoring and evaluation. The up-to-date status of screening programmes and adherence to selected recommendations was gathered from official documentation and co-authors representing cervical cancer screening programmes in all the Nordic countries.

RESULTS

A total of 168 recommendations were extracted and 54 of them were considered to be unambiguous and relevant. Forty-nine recommendations were included after synthesising similar recommendations. All Nordic countries adhere to recommendations related to legal framework, but adherence was lower with recommendations related to governance and organisation of screening. Monitoring and evaluation are also areas where adherence to recommendations could be improved.

CONCLUSIONS

The Nordic cervical cancer screening programmes have substantially decreased cancer burden despite not fully adhering to many of the recommendations. The presented gaps in adherence suggest that there is room for improvement in the screening programmes. Establishing clearer governance structures would still increase the ability to manage changes such as implementing HPV testing as the primary screening method or modifying the programme when HPV vaccinated cohorts of women enter the target age for screening.

Post-reproductive aged women: a lost generation in the cervical cancer screening programme

OBJECTIVES

The aims of the study were to find out why some post-reproductive aged women did not participate in the organised cervical cancer screening programme in Latvia and to clarify factors that would motivate them to take part.

METHODS

A cross-sectional study was carried out between January and July 2017 among female patients in three general practitioner (GP) practices. GP practice nurses used the Latvian national health service database to identify women aged 25-70 who had not participated in the organised programme for the last 3 years. Participants were asked to complete a specially developed questionnaire. The results were then compared between three age groups: 25-34, 35-49 and 50-70 years.

RESULTS

Included in the study were 523 out of 992 women who had not attended screening; 41% were in the age group 50-70 years. Post-reproductive aged women statistically significantly more often did not take part in the programme because of lack of time (26.4%), too great a distance to the gynaecology screening clinic (10.4%), lengthy appointment waiting time (8.5%) and a belief that a smear test was unnecessary for them (8.5%); 32.1% of women in this age group indicated that if the cervical screen could be carried out by their GP it would facilitate their participation in the programme.

CONCLUSION

Post-reproductive aged women in Latvia often do not attend cervical cancer screening. Analysis of personal and organisational barriers confirmed that the involvement of GPs would encourage older women to participate in the organised screening programme.

Cervical Cancer Screening Participation among Women of Russian, Somali, and Kurdish Origin Compared with the General Finnish Population: A Register-Based Study

Migrant-origin women are less prone to cervical screening uptake compared with host populations. This study examined cervical cancer screening participation and factors associated with it in the Finnish mass screening program during 2008–2012 in women of Russian, Somali and Kurdish origin compared with the general Finnish population (Finns) in Finland. The study population consists of samples from the Finnish Migrant Health and Well-being Study 2010–2012 and Health 2011 Survey; aged 30–64 (n = 2579). Data from the Finnish screening register linked with other population-based registry data were utilized. For statistical analysis we employed logistic regression. Age-adjusted screening participation rates were Russians 63% (95% CI: 59.9–66.6), Somalis 19% (16.4–21.6), Kurds 69% (66.6–71.1), and Finns 67% (63.3–69.8). In the multiple-adjusted model with Finns as the reference; odds ratios for screening were among Russians 0.92 (0.74–1.16), Somalis 0.16 (0.11–0.22), and Kurds 1.37 (1.02–1.83). Among all women, the substantial factor for increased screening likelihood was hospital care related to pregnancy/birth 1.73 (1.27–2.35), gynecological 2.47 (1.65–3.68), or other reasons 1.53 (1.12–2.08). Screening participation was lower among students and retirees. In conclusion, screening among the migrant-origin women varies, being significantly lowest among Somalis compared with Finns. Efforts using culturally tailored/population-specific approaches may be beneficial in increasing screening participation among women of migrant-origin.

Barriers and Facilitators to Cervical Screening among Migrant Women of African Origin: A Qualitative Study in Finland

Globally, cervical cancer constitutes a substantial public health concern. Evidence recommends regular cervical cancer screening (CCS) for early detection of "precancerous lesions."Understanding the factors influencing screening participation among various groups is imperative for improving screening protocols and coverage. This study aimed to explore barriers and facilitators to CCS participation in women of Nigerian, Ghanaian, Cameroonian, and Kenyan origin in Finland. We utilized a qualitative design and conducted eight focus group discussions (FGDs) in English, with women aged 27-45 years (n = 30). The FGDs were tape-recorded, transcribed verbatim, and analyzed utilizing the inductive content analysis approach. The main barriers to CCS participation included limited language proficiency, lack of screening awareness, misunderstanding of screening's purpose, and miscomprehension of the CCS results. Facilitators were free-of-charge screening, reproductive health services utilization, and women's understanding of CCS's importance for early detection of cervical cancer. In conclusion, among women, the main barriers to CCS participation were language difficulties and lack of screening information. Enhancing screening participation amongst these migrant populations would benefit from appropriate information about the CCS. Those women with limited language skills and not utilizing reproductive health services need more attention from healthcare authorities about screening importance. Culturally tailored screening intervention programs might also be helpful.

Differences in cervical test coverage by age, socioeconomic status, ethnic origin and municipality type - A nationwide register-based study

An invitational organized cervical cancer screening together with widely spread opportunistic testing has coexisted for decades in Finland. The aim of this study was to examine the coverage of cervical tests by age, socioeconomic status, ethnicity and municipality type within and outside the organized screening program. We had a cohort of women of whom 1,2 million were in the target age range of screening and residing in Finland in 2010-2014. Data on Pap and/or HPV -tests within and outside the screening program were collected from the Mass Screening Registry, the pathology laboratories and the health insurance reimbursement registry and five-year population coverages of tests were reported. The total test coverage was 86.0%; 95% CI, (85.8-86.1), and was notably lower for those with an unknown socioeconomic status and pensioners (68.8%; 95% CI, (67.9-69.6) and 77.1%; 95% CI, (76.5-77.6), respectively) compared to upper-level employers (89.8%; 95% CI, (89.5-90.2)). Coverage was also lower for non-native speaking women (72.4%; 95% CI, (71.8-73.0)) compared to native speakers (86.9%; 95% CI, (86.7-87.0)) and for women living in urban municipalities (85.5%; 95% CI, (85.3-85.7)) compared to semi-urban (87.4%; 95% CI, (87.0-87.8)). Although overall coverage was high, tests within and outside the program seemed to concentrate on women with presumably good access to health services. Tests outside the program were especially common among young women who are at a low risk of invasive cervical cancer. Efforts should be made to reduce excessive opportunistic testing and to increase attendance at the program among hard-to-reach populations.

Self-collection of samples for HPV testing to increase participation in cervical cancer screening by immigrant women: An integrative review

OBJECTIVE

To examine methods and results of studies assessing self-collection of cervico-vaginal samples for human papillomavirus (HPV) testing by immigrant women for insights into how future research using this method with unique subpopulations of women may improve the rates of cervical cancer screening (CCS) compared to current strategies.

DATA SOURCES

Four electronic databases were systematically searched through March 2020, with no limits applied. A manual review of reference lists was also completed.

STUDY SELECTION

The search resulted in 63 articles. After removal of duplicates, 36 were reviewed against inclusion criteria. A manual review of reference lists yielded two additional studies. The final sample included 15 relevant publications representing 13 unique empirical studies.

DATA EXTRACTION

Data related to study methodology and empirical results were extracted into table form.

DATA SYNTHESIS

The methods of the studies were summarized and synthesized, including diversity of participants, community engagement, including collaboration with public health nurses or community health workers. In addition, methods and findings related to the educational components of the studies, and empirical findings related to various cultural groups, were described.

CONCLUSION

To reduce health disparities in CCS, researchers should focus on diverse groups, such as immigrant women, to understand important individual and group-specific factors that may influence screening, including whether self-collection of samples for HPV testing along with appropriate education and support for follow-up will address these factors.

Cost-effectiveness studies of HPV self-sampling: A systematic review

HPV self-sampling (HPV-SS) can increase cervical cancer screening participation by addressing barriers in high- and low- and middle-income settings. Successful implementation of HPV-SS programs will depend on understanding potential costs and health effects. Our objectives were to summarize the methods and results of published HPV-SS cost and cost-effectiveness studies, present implications of these results for HPV-SS program implementation, and identify knowledge gaps. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. One reviewer searched online databases for articles published through June 12, 2019, identified eligible studies, and extracted data; a second reviewer checked extracted data for accuracy. Eligible studies used an economic model to compare HPV-SS outreach strategies to standard-of-care tests. Of 16 eligible studies, 14 reported HPV-SS could be a cost-effective strategy. Studies differed in model type, HPV-SS delivery methods, triage strategies for positive results, and target populations. Most (9/16) modeled HPV-SS in European screening programs, 6/16 targeted women who were underscreened for cervical cancer, and 5/16 modeled HPV-SS in low- and middle-income countries. The most commonly identified driver of HPV-SS cost-effectiveness was the level of increase in cervical cancer screening attendance. Lower HPV-SS material and testing costs, higher sensitivity to detect cervical precancer, and longer duration of underscreening among HPV-SS users were also associated with increased cost-effectiveness. Future HPV-SS models in high-income settings should explore the effect of widespread vaccination and new triage strategies such as partial HPV genotyping. Knowledge gaps remain about the cost-effectiveness of HPV-SS in low- and middle-income settings.

The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Organised Versus Opportunistic Cervical Cancer Screening in Urban and Rural Regions of Lithuania

Background and Objectives: In 2004, Lithuania started the Nationwide Cervical Cancer Screening Programme. However, screening is more opportunistic than population-wide and the programme’s coverage is insufficient. The aim of this study was to assess the effect of systematic personal invitation on coverage of cervical cancer (CC) screening in urban and rural regions of Lithuania. Materials and Methods: The study was conducted in an urban primary healthcare centre (PHCC) and in a rural PHCC, where prevailing CC screening practice was highly opportunistic. Over the first year, all women aged 25–60 who had not received a Pap smear test within the last three years in urban (n = 1591) and rural (n = 1843) PHCCs received a personal invitation letter to participate in the screening. Over the second year, the reminder letter was sent to the non-attendees (n = 1042 in urban and n = 929 in rural PHCCs). A random sample of women (n = 93), who did not attend for screening after two letters, was contacted by phone in order to identify the barriers of non-attendance. Results: Before the study, only 9.6% of the target population in urban and 14.7% in rural PHCCs participated in CC screening. After the first invitation letter, the participation in CC screening increased up to 24.6% in urban and 30.8% in rural areas (p < 0.001). After the reminder letter, the attendance was 16.4% in urban and 22.2% in rural PHCCs (p < 0.001). The most common barriers for the non-attendance were lack of time, long waiting time for family doctor’s appointment, worries that a Pap test might be unpleasant and preventive gynaecological examination outside of the screening program. Conclusions: A systematic personal invitation with one reminder letter significantly increased the coverage of CC screening and was more effective in rural regions than in urban regions. The assessed barriers for non-attendance can be used to improve the coverage of screening.

What Has Changed Since the Introduction of Human Papillomavirus Testing with the Cytology-Based Cervical Cancer Screening System in Japan A Social Experiment

BACKGROUND

Uterine cervical cancer is the fourth most common female cancer in the world. In Japan, we have an apparently low rate of joining cervical cancer screening programs compared with Western countries. Furthermore, the incidence and mortality rate of cervical cancer among the younger generation has been increasing.

OBJECT

The aim of this study was to assess the effectiveness of cervical cancer screening with human papillomavirus (HPV) testing and cytology in Japan.

METHODS

Collaborating with Saga City government, we initiated a cervical cancer screening system consisting of HPV testing and baseline cervical cytology from April 2011 as a social experiment. A total of 17,284 participants have been screened with this new combination system.

RESULTS

After HPV testing with cytology-based cervical cancer screening, the number of screenings done in women aged under 40 years has significantly increased. In addition, the number of women diagnosed with cervical intraepithelial neoplasia grade 3 has increased (25 of 14,025 vs. 146 of 23,049 under 50 years: p < 0.001).

CONCLUSION

These data suggested that the introduction of HPV testing with cytology-based cervical cancer screening as an adjunct to conventional cytology resulted in better efficiency and more accurate screening among the Japanese population.

Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis

Introduction

Human papillomavirus (HPV) self-sampling test kits may increase screening for and early detection of cervical cancer and reduce its burden globally. To inform WHO self-care guidelines, we conducted a systematic review and meta-analysis of HPV self-sampling among adult women on cervical (pre-)cancer screening uptake, screening frequency, social harms/adverse events and linkage to clinical assessment/treatment.

Methods

The included studies compared women using cervical cancer screening services with HPV self-sampling with women using standard of care, measured at least one outcome, and were published in a peer-reviewed journal. We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature (CNIAHL), Latin American and Caribbean Health Sciences Literature (LILACS) and Embase through October 2018. Risk of bias was assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for non-randomised studies. Meta-analysis was conducted using random-effects models to generate pooled estimates of relative risk (RR).

Results

33 studies in 34 articles with 369 017 total participants met the inclusion criteria: 29 RCTs and 4 observational studies. All studies examined HPV self-sampling; comparison groups were standard of care (eg, Pap smear, visual inspection with acetic acid, clinician-collected HPV testing). 93% of participants were from high-income countries. All 33 studies measured cervical cancer screening uptake. Meta-analysis found greater screening uptake among HPV self-sampling participants compared with control (RR: 2.13, 95% CI 1.89 to 2.40). Effect size varied by HPV test kit dissemination method, whether mailed directly to home (RR: 2.27, 95% CI 1.89 to 2.71), offered door-to-door (RR: 2.37, 95% CI 1.12 to 5.03) or requested on demand (RR: 1.28, 95% CI 0.90 to 1.82). Meta-analysis showed no statistically significant difference in linkage to clinical assessment/treatment between arms (RR: 1.12, 95% CI 0.80 to 1.57). No studies measured screening frequency or social harms/adverse events.

Conclusion

A growing evidence base, mainly from high-income countries and with significant heterogeneity, suggests HPV self-sampling can increase cervical cancer screening uptake compared with standard of care, with a marginal effect on linkage to clinical assessment/treatment.

Systematic review registration number

PROSPERO CRD42018114871.

Testing the psychometric properties of the Finnish version of the cross-cultural competence instrument of healthcare professionals (CCCHP)

Background

To test the validity of the Finnish version of the Bernhard et al.’s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP).

Methods

The study sample comprised registered nurses (N = 810) from the Finnish “Competent workforce for the future” -project (COPE). Exploratory factor analyses and structural equation modelling were applied to test structural validity of the CCCHP. Internal consistency of the sub-scales was evaluated using the Cronbach’s alphas. Criterion validity was explored in terms of received education for multicultural work, perceived difficulty of patients, and job satisfaction variables.

Results

The revised version of the instrument including four (motivation/curiosity, attitudes, skills and emotions/empathy) of the five original dimensions provided satisfactory psychometric properties (internal consistency, a good model fit of the data). Of the four remaining competence sub-scales, motivation/curiosity, attitudes and emotions/empathy were associated with the amount of received education for multicultural work, and all with perceived difficulty of patients, and all but attitudes with job satisfaction.

Conclusion

This revised Finnish version of the CCCHP provides a useful tool for studies focusing on the healthcare personnel’s cross-cultural competence in delivering effective and culturally sensitive healthcare services for patients from different cultures.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4105-2) contains supplementary material, which is available to authorized users.

Development and evaluation of a cervical cancer screening system in Cambodia: A collaborative project of the Cambodian Society of Gynecology and Obstetrics and Japan Society of Obstetrics and Gynecology

Aim

In Cambodia, the Japan Society of Obstetrics and Gynecology and the Cambodian Society of Gynecology and Obstetrics have an on‐going project, started in 2015, for cervical cancer prevention and treatment. The project, currently aimed at factory workers, includes a women’s health education program that leads into cervical cancer prevention by establishment of a system for early detection and treatment. It begins by health education, screening for human papillomavirus (HPV), followed by colposcopy and quicker treatment of earlier precursor lesions.

Methods

Rates for participant screening, HPV test positivity, cervical intraepithelial neoplasia (CIN) detection and distribution of HPV types were compared between two screening programs, factory‐based and hospital‐based. Some HPV test samples were divided into two, one of which was sent to Japan for a quality‐control check of the Cambodian testing.

Results

The factory‐based participant screening rate was 19% (128/681). HPV was detected more frequently in the factory‐based program participants (12%) than in the hospital‐based program participants (5%). Unfortunately, however, the rate of receiving proper secondary colposcopy screening among the HPV‐positive females was significantly higher in the hospital‐based program (94%) than the factory‐based program (40%) (P < 0.001). The Cambodian laboratory HPV testing accuracy was 92.6%. HPV types demonstrated no significant difference between the two prevention programs.

Conclusion

We could successfully introduce HPV‐based screening, starting from health education. However, low rate of screening, especially secondary screening for HPV positive factory workers was identified. Also, HPV testing could be further improved for accuracy through close monitoring.

Moving towards an organized cervical cancer screening: costs and impact

Background

HPV screening has been shown to be more cost-effective than cytology screening under most scenarios. Furthermore, it should be offered only in organized programmes with good quality assurance mechanisms. This study analyses the comparative cost of the current policy of opportunistic cytology screening vs. a hypothetical organized programme based on primary HPV screening.

Methods

Total cervical cancer expenditure was defined as the sum of three cost elements: (i) direct (medical and non-medical) costs, obtained from a calibrated Markov model of the natural history of HPV and cervical cancer; (ii) programmatic costs, estimated based on other organized screening programmes; and (iii) indirect costs, extrapolated from previously published data.

Results

Organized HPV screening at 5-year intervals costs consistently less across all coverage levels than opportunistic cytology screening at 3-year intervals. The current annual direct medical cost to the public health system of the opportunistic cytology at 40% coverage is estimated at €33.2 per woman screened aged 25-64. Under an organized programme of primary HPV screening at 70% coverage, the cost is estimated to be €18.4 per woman screened aged 25-64.

Conclusion

Our study concludes that the economic resources currently devoted to providing opportunistic cytology screening to 40% of the target population at 3-year intervals could be more effectively used to screen 70% of the target population at 5-year intervals by switching to an organized programme based on primary HPV screening. This finding is of relevance to other European countries or regions with similar screening policies and health infrastructures.

Disparities in Cervical Cancer Screening Among Women With Disabilities: A National Database Study in South Korea

Purpose

Using the linked administrative database in Korea, we investigated (1) whether cervical cancer screening participation differed by the presence of varying degrees and types of disability; (2) trends in the cervical cancer screening rate relative to disabilities over time; and (3) factors associated with cervical cancer screening.

Methods

We linked national disability registration data with national cancer screening program data. Age-standardized participation rates were analyzed for each year during the period 2006 to 2015, according to the presence, type, and severity of disabilities. Factors associated with undergoing cervical cancer screening were examined by multivariate logistic regression with the most current data (ie, 2014 to 2015).

Results

The age-adjusted screening rate for cervical cancer screening in women with disabilities increased from 20.8% in 2006% to 42.1% in 2015 (change, +21.3%); however, among women without disabilities, it increased from 21.6% to 53.5% (change: +31.9%) during that time. Disability was associated with a lower screening rate (adjusted odds ratio [aOR], 0.71; 95% CI, 0.71 to 0.72). Screening rates were markedly lower in women with severe disabilities (aOR, 0.42; 95% CI, 0.42 to 0.42) and women with autism (aOR, 0.06; 95% CI 0.03 to 0.11), intellectual disability (aOR, 0.25; 95% CI, 0.25 to 0.26), brain injury (aOR, 0.311; 95% CI, 0.31 to 0.32), ostomy (aOR, 0.36; 95% CI, 0.33 to 0.38), or mental disorder (aOR, 0.43; 95% CI, 0.42 to 0.44).

Conclusion

Despite the availability of free screening, a significant disparity was found in cervical cancer screening participation, especially in women with severe disabilities and those with mental disabilities. The identification of barriers associated with decreased screening rates in women with disabilities has important implications for the design of tailored interventions and health care policies to improve cervical cancer screening and outcomes in this vulnerable population.

Factors associated with non-participation in cervical cancer screening - A nationwide study of nearly half a million women in Denmark

Cervical cancer occurs most often in under-screened women. In this nationwide register study, we described differences in sociodemographic characteristics between passive and active non-participants and examined socio-demographic characteristics, reproductive history, and mental and physical health as potential determinants for passive non-participation compared with participation in the Danish cervical cancer screening program. Screening history in women aged 23-49 years invited for cervical cancer screening in 2008-2009 was retrieved from the Danish Pathology Databank with information about dates of invitation and unsubscription. We identified participants (n = 402,984), active non-participants (n = 10,251) and passive non-participants (n = 63,435) within four years following baseline invitation and retrieved data about the study population from high-quality registries. We examined differences in socio-demographic characteristics of passive and active non-participants, and used multiple logistic regression analyses to identify potential determinants of passive non-participation. We found that active and passive non-participants differed in relation to socio-demography. When compared with screening participants, the odds of passive non-participation was increased in women who originated from less developed countries; were unmarried; had basic education or low income; had four or more children; smoked during pregnancy; had multiple induced abortions; or had a history of obesity, intoxicant abuse or schizophrenia or other psychoses. In conclusion, in this nationwide, prospective, population-based study, differences in socio-demographic characteristics between passive and active non-participants were found. Furthermore, sociodemography, reproductive history, and mental and physical health were determinants for passive non-participation. Addressing inequalities in screening attendance may help to further decrease the incidence of and mortality from cervical cancer.

Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs

In most industrialized countries, screening programs for cervical cancer have shifted from cytology (Pap smear or ThinPrep) alone on clinician-obtained samples to the addition of screening for human papillomavirus (HPV), its main causative agent. For HPV testing, self-sampling instead of clinician-sampling has proven to be equally accurate, in particular for assays that use nucleic acid amplification techniques. In addition, HPV testing of self-collected samples in combination with a follow-up Pap smear in case of a positive result is more effective in detecting precancerous lesions than a Pap smear alone. Self-sampling for HPV testing has already been adopted by some countries, while others have started trials to evaluate its incorporation into national cervical cancer screening programs. Self-sampling may result in more individuals willing to participate in cervical cancer screening, because it removes many of the barriers that prevent women, especially those in low socioeconomic and minority populations, from participating in regular screening programs. Several studies have shown that the majority of women who have been underscreened but who tested HPV-positive in a self-obtained sample will visit a clinic for follow-up diagnosis and management. In addition, a self-collected sample can also be used for vaginal microbiome analysis, which can provide additional information about HPV infection persistence as well as vaginal health in general.

Significant variations in the cervical cancer screening rate in China by individual-level and geographical measures of socioeconomic status: a multilevel model analysis of a nationally representative survey dataset

Variations in cervical cancer screening rates in China have rarely been studied in depth. This study aimed to investigate cervical cancer screening rates in relation to both individual‐level and geographical measures of socioeconomic status (SES). Data were obtained from women aged 21 years or older by face‐to‐face interviews between August 2013 and July 2014 as part of the Chinese Chronic Diseases and Risk Factors Surveillance. The geographical variables were obtained from the 2010 Chinese population census. The cervical cancer screening rates and 95% confidence interval (CI) were estimated and mapped. Multilevel logistic regression models were fitted. Overall, only 21.4% (95% CI: 19.6–23.1%) of 91,816 women aged ≥21 years reported having ever been screened for cervical cancer and significant geographical variations at both province and county levels were identified (P < 0.01). The cervical cancer screening rates were the lowest among the poor [13.9% (95% CI: 12.1–15.7%)], uninsured [14.4% (95% CI: 10.3–18.4%)], less‐educated [16.0% (95% CI: 14.3–17.6%)], and agricultural employment [18.1% (95% CI: 15.8–20.4%)] women along with those residing in areas of low economic status [15.0% (95% CI: 11.8–18.2%)], of low urbanization [15.6% (95% CI: 13.4–17.7%)], and of low education status [16.0% (95% CI: 14.0–18.1%)]. The multilevel analysis also indicated that women with lower individual‐level measures of SES residing in areas with low geographical measures of SES were significantly less likely to receive cervical cancer screening (P < 0.0001). Despite the launch of an organized cancer screening program in China, cervical cancer screening rates remain alarmingly low and significant variations based on geographical regions and measures of SES still exist. It is therefore essential to adopt strategies to better direct limited available public resources to priority groups.

Factors associated with participation in cervical cancer screening among young Koreans: a nationwide cross-sectional study

OBJECTIVES

Despite the possibility of early detection of cervical cancer, participation in screening programmes among young Koreans is low. We sought to identify associations between risk factors and participation in screening for cervical cancer among young Koreans.

DESIGN

Nationwide cross-sectional study.

SETTING

Republic of Korea.

PARTICIPANTS

3734.

MAIN OUTCOME MEASURES

The Korea National Health and Nutrition Examination Survey (KNHANES V: 2010-2012) was used to evaluate factors associated with attendance for cervical cancer screening among women aged 15-39. After excluding those who were previously diagnosed with cervical cancer and those with incomplete responses to questionnaires, a total of 3734 subjects were eligible. Multi-dimensional covariates as potential predictors of cervical cancer screening were adjusted in multiple logistic regression analysis.

RESULTS

The participation rate for cervical cancer screening was 46% among women aged 40 or younger. The logistic analyses showed that age, education, total household income, smoking and job status among women aged 15-39 were associated with participation in cervical cancer screening (p<0.05). After age stratification, the associated factors differed by age groups. Moreover, a dose-response between participation in cervical cancer screening and high total household income in the 30-39 age group was seen.

CONCLUSIONS

Predictive factors differed among young women (aged 15-29 vs 30-39). Thus, age-specific tailored interventions and policies are needed to increase the participation rate in screening for cervical cancer.

Factors associated with cervical cancer screening participation among immigrants of Russian, Somali and Kurdish origin: a population-based study in Finland

Background

Previous studies revealed low participation in cervical cancer screening among immigrants compared with non-immigrants. Only a few studies about factors associated with immigrants’ lower participation rates have been conducted in European countries that have universal access for all eligible women. Our study aimed to explore factors associated with cervical screening participation among women of Russian, Somali, and Kurdish origin in Finland.

Methods

We used data from the Migrant Health and Well-being Survey, 2010-2012. Structured face-to-face interviews of groups of immigrants aged 25-60 yielded 620 responses concerning screening participation in the previous five years. Statistical analysis employed logistic regression.

Results

The age-adjusted participation rates were as follows: among women of Russian origin 73.9% (95% CI 68.1-79.7), for Somalis 34.7% (95% CI 26.4-43.0), and for Kurds 61.3% (95% CI 55.0-67.7). Multiple logistic regressions showed that the most significant factor increasing the likelihood of screening participation among all groups was having had at least one gynecological check-up in the previous five years (Odds ratio [OR] = 6.54-26.2; p < 0.001). Other factors were higher education (OR = 2.63; p = 0.014), being employed (OR = 4.31; p = 0.007), and having given birth (OR = 9.34; p = 0.014), among Kurds; and literacy in Finnish/Swedish (OR = 3.63; p = 0.003) among Russians.

Conclusions

Our results demonstrate that women who refrain from using reproductive health services, those who are unemployed and less educated, as well as those with poor language proficiency, might need more information on the importance of screening participation. Primary and occupational healthcare services may have a significant role in informing immigrant women about this importance.

Methylation analysis and HPV genotyping of self-collected cervical samples from women not responding to screening invitation and review of the literature

Aim of the study

To assess the feasibility of partial HPV genotyping and methylation analysis of CADM1, MAL, and miR124-2 genes as triage tests in assaying self-collected cervical samples positive for high-risk HPV on primary screening, and to review the literature regarding host cellular gene methylation analysis of self-collected cervical samples.

Material and methods

Women residing in North-East Italy who had failed to respond to the invitation to participate in an organized population-based program were invited to provide a self-sample. Their stored baseline (self-collected) and follow-up (clinician-collected) cervical samples were included in the study. DNA was extracted from HPV-positive (Qiagen’s Hybrid Capture 2, HC2) samples. Partial genotyping with separate detection of HPV types 16 and 18 was performed with a hybrid capture-based method and a quantitative PCR assay. Methylation was assayed with a quantitative methylation-specific PCR.

Results

High-risk HPV infection was detected in 48% of baseline and 71% of follow-up HC2-positive samples. Methylation was demonstrated respectively in 15% and 23.5% of baseline and follow-up samples and chiefly involved a single gene (miR124-2). Invalid quantitative PCR results were recorded in 5% of self-collected samples. The specificity of miR124-1, MAL, and CADM1 methylation was 84%, 94%, and 98%, respectively, and the specificity of the three markers combined was 84%. Sensitivity was not estimated due to the lack of CIN2+ samples. The systematic review showed that different methylation assays yield different accuracy values.

Conclusion

Self-collected samples are suitable for methylation assays included in reflex triage testing. The reproducibility and accuracy of the methylation tests described in the literature should be improved.

Cost-effectiveness of strategies to increase screening coverage for cervical cancer in Spain: the CRIVERVA study

BACKGROUND

The aim of the study is to carry out a cost-effectiveness analysis of three different interventions to promote the uptake of screening for cervical cancer in general practice in the county of Valles Occidental, Barcelona, Spain.

METHODS

Women aged from 30 to 70 years (n = 15,965) were asked to attend a general practice to be screened. They were randomly allocated to one of four groups: no intervention group (NIG); one group where women received an invitation letter to participate in the screening (IG1); one group where women received an invitation letter and informative leaflet (IG2); and one group where women received an invitation letter, an informative leaflet and a phone call reminder (IG3). Clinical effectiveness was measured as the percentage increase in screening coverage. A cost-effectiveness analysis was performed from the perspective of the public health system with a time horizon of three to five years - the duration of the randomised controlled clinical trial. In addition, a deterministic sensitivity analysis was performed. Results are presented according to different age groups.

RESULTS

The incremental cost-effectiveness ratio (ICER) for the most cost-effective intervention, IG1, compared with opportunistic screening was € 2.78 per 1% increase in the screening coverage. The age interval with the worst results in terms of efficiency was women aged < 40 years.

CONCLUSIONS

In a population like Catalonia, with around 2 million women aged 30 to 70 years and assuming that 40% of these women were not attending general practice to be screened for cervical cancer, the implementation of an intervention to increase screening coverage which consists of sending a letter would cost on average less than € 490 for every 1000 women.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01373723 .

Personal and provider level factors influence participation to cervical cancer screening: A retrospective register-based study of 1.3 million women in Norway

High coverage is essential for an effective screening programme. Here we present screening barriers and facilitators among 1.3 million women aged 25-69years eligible for screening within the Norwegian Cervical Cancer Screening Program (NCCSP). We defined non-adherence as no screening test in 2008-2012. We divided adherent women into those screened spontaneously, and those who had a smear after receiving a reminder from the NCCSP. Explanatory variables were extracted from several nationwide registers, and modelled by modified Poisson regression. In total, 34% of women were non-adherent. 31% of native Norwegians were non-adherent, compared to 50% of immigrants. Immigrant status was a strong predictor of non-adherence, but the vast majority of non-adherent women were still native Norwegians. Higher non-adherence rates were associated with having a male general practitioner (GP), a foreign GP, a young GP, and distance to the screening site. Being unmarried, having no children, having lower socioeconomic position and region of residence predicted non-adherence and, to a smaller extent, reminded adherence to screening. In contrast, previous experience with cervical abnormalities substantially increased adherence to screening. The population-based screening programme promotes equity by recruiting women who are less likely to participate spontaneously. However, socioeconomic disparities were evident in a country with a nationwide programme and a policy of equal access to health care. Initiatives aimed at removing practical and financial barriers to equitable screening delivery and at reducing the effect of sociodemographic attributes on screening participation are needed.

Impact of scheduled appointments on cervical screening participation in Norway: a randomised intervention

BACKGROUND

The main barrier to optimal effect in many established population-based screening programmes against cervical cancer is low participation. In Norway, a routine health service integrated population-based screening programme has been running since 1995, using open invitations and reminders. The aim of this randomised health service study was to pilot scheduled appointments and assess their potential for increased participation.

METHODS

Within the national screening programme, we randomised 1087 women overdue for screening to receive invitations with scheduled appointments (intervention) or the standard open reminders (control). Letters were sent 2-4 weeks before the scheduled appointments at three centres: a midwife clinic, a public healthcare centre and a general practitioner centre. The primary outcome was participation at 6 months of follow-up. Secondary outcomes were participation at 1 and 3 months. Risk ratios (RRs) overall, and stratified by screening centre, age group and previous participation, were calculated using log-binomial regression.

RESULTS

At 6 months, 20% of the 510 women in the control group and 37% of the 526 women in the intervention group had participated in screening, excluding 51 women in total from analysis due to participation just before invitation and therefore not yet visible in the central records. The RR for participation at 6 months was 1.9 (95% CI 1.5 to 2.3). There was no significant heterogeneity between centres or age groups. Participation increased among women both with (RR 1.7; 95% CI 1.4 to 2.1) and without (RR 3.5; 95% CI 1.3 to 9.2) previous participation. The RRs for participation at 1 and 3 months were 4.0 (95% CI 2.6 to 6.2) and 2.7 (95% CI 2.1 to 3.5), respectively.

CONCLUSIONS

Scheduled appointments increased screening participation consistently across all target ages and screening centres among women overdue for screening. Participation increased also among women with no previous records of cervical screening.

An empirical study of the 'underscreened' in organised cervical screening: experts focus on increasing opportunity as a way of reducing differences in screening rates

BACKGROUND

Cervical cancer disproportionately burdens disadvantaged women. Organised cervical screening aims to make cancer prevention available to all women in a population, yet screening uptake and cancer incidence and mortality are strongly correlated with socioeconomic status (SES). Reaching underscreened populations is a stated priority in many screening programs, usually with an emphasis on something like 'equity'. Equity is a poorly defined and understood concept. We aimed to explain experts' perspectives on how cervical screening programs might justifiably respond to 'the underscreened'.

METHODS

This paper reports on a grounded theory study of cervical screening experts involved in program organisation. Participants were 23 experts from several countries and a range of backgrounds: gynecology; epidemiology; public health; pathology; general practice; policy making. Data were gathered via semi-structured interview and concepts developed through transcript coding and memo writing.

RESULTS

Most experts expressed an intuitive commitment to reducing systematic differences in screening participation or cancer outcomes. They took three different implicit positions, however, on what made organised programs justifiable with respect to underscreened populations. These were: 1) accepting that population screening is likely to miss certain disenfranchised groups for practical and cultural reasons, and focusing on maximising mainstream reach; 2) identifying and removing barriers to screening; and 3) providing parallel tailored screening services that attended to different cultural needs. Positions tended to fall along country of practice lines.

CONCLUSIONS

Experts emphasised the provision of opportunity for underscreened populations to take up screening. A focus on opportunity appeared to rely on tacit premises not supported by evidence: that provision of meaningful opportunity leads to increased uptake, and that increased uptake of an initial screening test by disadvantaged populations would decrease cervical cancer incidence and mortality. There was little attention to anything other than the point of testing, or the difficulties disadvantaged women can have in accessing follow up care. The different approaches to 'improving equity' taken by participants are differently justified, and differently justifiable, but none attend directly to the broader conditions of disadvantage.

Comparative effectiveness of two outreach strategies for cervical cancer screening

OBJECTIVE

Test-specific reminder letters can improve cancer screening adherence. Little is known about the effectiveness of a reminder system that targets the whole person by including multiple screening recommendations per letter.

METHODS

We compared the effectiveness of a Pap-specific reminder letter sent 27months after a woman's last Pap, to a reminder letter that included up to seven preventive service recommendations sent before a woman's birthday ("birthday letter") on Pap smear adherence from a natural experiment occurring in routine clinical care. Participants included 82,016 women from Washington State who received 72,615 Pap-specific letters between 2003 and 2007 and 100,218 birthday letters between 2009 and 2012. We defined adherence as having a Pap test within a six month window around the Pap test due date. Using logistic regression, we calculated adjusted odds ratios (OR) for adherence with 95% confidence intervals (CI) following the birthday letter with 1-2 recommendations, 3-5 recommendations, and 6-7 recommendations compared to the Pap-specific letter. All analyses were stratified by whether a woman was up-to-date or overdue for screening at the time she received a letter.

RESULTS

Adjusted ORs showed reduced adherence following the birthday letter compared with the Pap-specific letter for up-to-date women whether the letter had 1-2 recommendations (OR=0.37, 95%CI=0.36-0.39), 3-5 recommendations (OR=0.44, 95%CI=0.42-0.45), or 6-7 recommendations (OR=0.36, 95%CI=0.32-0.40). We noted no difference in Pap-test adherence between letter types for overdue women.

CONCLUSIONS

In conclusion, for women regularly adherent to screening, an annual birthday letter containing reminders for multiple preventive services was less effective at promoting cervical cancer screening compared with a Pap-specific letter.

Self-sampling in cervical cancer screening: comparison of a brush-based and a lavage-based cervicovaginal self-sampling device

BACKGROUND

High coverage and attendance is essential for cervical cancer screening success. We investigated whether the previous positive experiences on increasing screening attendance by self-sampling in Finland are sampler device dependent.

METHODS

All women identified to cervical cancer screening in 2013 in 28 Finnish municipalities were randomised to receive a lavage- (n = 6030) or a brush type of self-sampling device (n = 6045) in case of non-attendance after two invitation letters. Seven hundred seventy non-attending women in the lavage device group and 734 in the brush group received the self-sampling offer. Women's experiences were enquired with an enclosed questionnaire.

RESULTS

Total attendance in the lavage group increased from 71.0 to 77.7% by reminder letters and further to 80.5% by self-sampling. Respective increase in the brush group was from 72.2 to 78.6% and then to 81.5%. The participation by self-sampling was 21.7% (95% CI 18.8-24.6) in the lavage group and 23.8% (95% CI 20.8-26.9) in the brush group. Women's self-sampling experiences were mainly positive and the sampler devices were equally well accepted by the women.

CONCLUSION

Our study shows that the lavage device and brush device perform similarly in terms of uptake by non-attending women and user comfort. If self-sampling is integrated to the routine screening program in Finland, either of the devices can be chosen without the fear of losing participants due to a less acceptable device.

The costs of offering HPV-testing on self-taken samples to non-attendees of cervical screening in Finland

Background

Offering self-sampling to non-attendees of cervical screening increases screening attendance.

Methods

We used observations from two Finnish studies on the use of self-sampling among the non-attendees to estimate in a hypothetical screening population of 100,000 women the possible costs per extra screened woman and costs per extra detected and treated CIN2+ with three intervention strategies; 1) a primary invitation and a reminder letter, 2) a primary invitation and a mailed self-sampling kit and 3) two invitation letters and a self-sampling kit. The program costs were derived from actual performance and costs in the original studies and a national estimate on management costs of HPV related diseases.

Results

The price per extra participant and price per detected and treated CIN2+ lesion was lower with a reminder letter than by self-sampling as a first reminder. When self-sampling was used as a second reminder with a low sampler price and a triage Pap-smear as a follow-up test for HPV-positive women instead of direct colposcopy referral, the eradication of a CIN2+ lesion by self-sampling was not more expensive than in routine screening, and the addition of two reminders to the invitation protocol did not increase the price of an treated CIN2+ lesion in the entire screened population.

Conclusions

As a first reminder, a reminder letter is most likely a better choice. As second reminder, the higher costs of self-sampling might be compensated by the higher prevalence of CIN2+ in the originally non-attending population.

Effectiveness of three interventions in improving adherence to cervical cancer screening

In countries where cervical cancer screening programmes are conducted on an opportunistic basis, an active search for women at risk should be made to increase coverage. The objective of our study was to assess the effectiveness of three primary care interventions consisting of providing written, telephone and face-to-face information to increase screening participation among women over the age of 25 years. A randomized experimental study with only one post-test control group was conducted on women aged 25-70 years. A total of 1676 women were randomly distributed into four groups and the following interventions were implemented: written briefing; telephone briefing; an invitation to attend a group meeting and no briefing (control group). The women were evaluated 2 years after the intervention. The outcome variable was participation or nonparticipation in cervical cancer screening. It proved possible to interview a total of 1122 women. Among the groups, homogeneity was tested in terms of sociodemographic characteristics and health-related variables. Women who had undergone cytological testing in the 2 years preceding evaluation had a lower mean age (P<0.001) than women who had not done so (45.5±11.0 vs. 48.8±13.0 years). The proportion of women who had participated in screening was as follows: 35.3% in the written information group [95% confidence interval (CI) 29.8-40.9]; 38.4% in the telephone information group (95% CI 32.5-44.2); 29.3% in the face-to-face information group (95% CI 22.8-35.7) and 26.1% in the control group (95% CI 21.2-30.9), with this difference proving statistically significant (P=0.005). Logistic regression showed that only the interventions based on written or telephone briefing were effective vis-à-vis the control group. In conclusion, both written and telephone information can serve to improve women's participation in opportunistic cervical cancer screening. Current preventive strategies could be optimized by means of simple interventions within the scope of health professionals.

Trends in the cervical cancer screening rates in a city in Japan between the years of 2004 and 2013

BACKGROUND

The objective of our study was to evaluate trends in the cervical cancer screening rate in a city in Japan between the years of 2004 and 2013.

METHODS

The cervical cancer screening rates for all female residents 20-49 years of age living in Toyonaka City for each year between 2004 and 2013 were analyzed and the effects of reminder letters and a free coupon program for cervical cancer screening on the subjects' behavior were evaluated.

RESULTS

The screening rate increased on a single-year basis from 8.9 % (2004) to 12.7 % (2009) as a result of the free coupon program. From 2009 onward, the screening rate on a single-year basis remained stable. Although the free coupon program increased the rate of screening participation, it did not achieve a continuous increase in the number of subjects undergoing screening. Furthermore, despite recommendations for biennial screening, some subjects participated in consecutive screening within the last 2 years after receiving visits for a regularly scheduled residential screening program 1 year before/after the current screening program with a free coupon. There was a peak in the rate of screening participation at the end of the fiscal year among females eligible for the free coupon program.

CONCLUSIONS

Excessive cervical cancer screening performed unnecessarily in the young is an unexpected limitation of free coupon programs. Further efforts to improve the screening rates are required, and the various factors leading young Japanese females to have a negative attitude toward cervical cancer screening should be identified.

The implementation of an organised cervical screening programme in Poland: an analysis of the adherence to European guidelines

BACKGROUND

Well-organised quality-controlled screening can substantially reduce the burden of cervical cancer (CC). European guidelines (EuG) for quality assurance in CC screening provide guidance on all aspects of an organised screening programme. Organised CC screening in Poland was introduced in 2007. The purpose of our study was to analyse: (i) adherence of the programme to EuG; (ii) programme process and performance indicators; (iii) impact of the programme on the incidence of and mortality from CC.

METHODS

Available data on the policy, structure and functioning of the Polish programme were compared with the major points of the EuG. Data on the process, and available performance indicators were drawn from the screening database and other National Health Fund (NHF) systems. Joinpoint regression was used to assess changes in CC incidence and mortality trends.

RESULTS

The Polish programme adheres partially to EuG in terms of policy and organisation. Only a limited set of performance indicators can be calculated due to screening database incompleteness or lack of linkage between existing databases. The screening database does not include opportunistic smears collected within NHF-reimbursed or private care. The organised programme coverage rate fluctuated from 21% to 27% between 2007-2013. In 2012 the coverage reached 35% after combining both organised and opportunistic smears reimbursed by the NHF. In 2012 the number of smears reimbursed by NHF was 60% higher in opportunistic than in organised screening with significant overlap. Data from the private sector are not recorded. Depending on years, 30-50% of women referred for colposcopy/biopsy because of abnormal Pap smears were managed within the programme. The age-standardised CC incidence and mortality dropped linearly between 1999 and 2011 without evidence of a period effect.

CONCLUSIONS

The Polish organised cervical screening programme is only partially adherent to evidence-based EuG. Its implementation has not influenced the burden of CC in the country so far. Changes with special focus on increasing coverage, development of information systems and assessment of quality are required to increase programme adherence to EuG and to measure its effectiveness. Our findings may be useful to improve the Polish programme and those implemented or planned in other countries.