An der Schwelle zum organisierten Zervixkarzinomscreening

Evaluations of the 2019 Annual Statistics Under the Cervical Cytology Quality Assurance Agreement: 2019 Annual Statistics for Cervical Cytology from 15608413 Women

Background

Cervical cancer screening, which was introduced into the programme of medical care covered by statutory health insurance in Germany in 1971 and has since been constantly updated through quality assurance measures, was fundamentally revised and developed in 2008 through the Cervical Cytology Quality Assurance Agreement pursuant to Section 135(2) of the German Social Code Book V [SGB V]. Since 2015 it has been mandatory for cytology facilities to record annual statistics based on the Munich Nomenclature III. The aim of this article is to present the results of the annual statistics for 2019, which was the last year before the introduction of the cervical cancer screening programme in accordance with the Federal Joint Committee's guideline on organised cancer screening programmes 1 .

Materials and Methods

The annual statistics of the laboratories, including histology analyses performed up until 30 June the following year, are reported to the Regional Associations of Statutory Health Insurance Physicians. The laboratories receive benchmark reports from their Regional Associations of Statutory Health Insurance Physicians, and these statistics are transmitted anonymously to the National Association of Statutory Health Insurance Physicians (KBV).

Results

In 2019, 17609082 smears from 15608413 women were examined in Germany. Of these smears, 97.49% were normal and 2.51% showed atypical or suspicious changes, consisting mostly of minor squamous epithelial changes in groups II-p (0.81%) and IIID1 (0.735%).Histology specimens are available for "Dysplasia findings with higher probability of regression" in group IIID1 (4.89% of initial IIID1 cytology findings), group IIID2 (18.60%), "unclear or doubtful findings" in group III-p to x (20.7%), and "immediate precursors to cervical carcinoma" in group IV (83.1%) and group V (77.19%).In the cytology findings for group IVa-p, which corresponds to CIN 3 target lesions, the cytology correlated with the histology finding in 80.48% of cases.Lesions found in 2019: 23463 CIN 3 lesions, 668 adenocarcinomas in situ, 3891 malignant tumours, including 2342 cervical carcinomas of which 1743 were squamous cell carcinomas and 599 were cervical adenocarcinomas (25.57%); 1549 endometrial carcinomas and other malignancies.

Inference/Conclusion

The data demonstrate the good practicability of cervical cancer screening in 2019. Higher grade lesions were reliably clarified histologically.

Cytology and High-Risk Human Papillomavirus Test for Cervical Cancer Screening Assessment

Background: A new nationwide screening strategy was implemented in Germany in January 2020. No data are available for women referred to certified dysplasia units for secondary clarification after primary diagnosis by a local physician. We therefore investigated combined testing with Papanicolaou smears and high-risk human papillomavirus (hrHPV) and compared the data with the final histological findings. Methods: Between January 2015 and October 2020, all referred women who underwent colposcopy of the uterine cervix in our certified dysplasia unit were included. Cytology findings were classified using the Munich III nomenclature. Results: A total of 3588 colposcopies were performed in 3118 women, along with Pap smear and hrHPV co-testing, followed by histology. Women with Pap II-p (ASC-US) and a positive hrHPV co-test had a 22.4% risk for cervical intraepithelial neoplasia (CIN) 3/high-grade squamous intraepithelial lesion (HSIL). The risk of CIN 3/HSIL was 83.8% in women with Pap IVa-p (HSIL) and a positive hrHPV co-test. A positive hrHPV co-test increased the risk for HSIL+ (OR 5.942; 95% CI, 4.617 to 7.649; p < 0.001) as compared to a negative hrHPV co-test. Conclusions: The accuracy of Pap smears is comparable with the screening results. A positive hrHPV test increases the risk for HSIL+ fivefold. Colposcopy is necessary to diagnose HSIL+ correctly.

Healthcare Costs and Resource Use Associated With Cervical Intraepithelial Neoplasia and Cervical Conization: A Retrospective Study of German Statutory Health Insurance Claims Data

Background: Cervical intraepithelial neoplasia (CIN) can be a consequence of human papillomavirus (HPV) infection. High-grade CIN (CIN2/CIN3) may develop from persistent HPV infection and progress to cervical cancer if left untreated. Management of CIN includes conservative surveillance or ablation and excision by conization. Internationally, CIN and its treatment generate a considerable economic burden, but no current data regarding costs and resource use from the perspective of the German statutory health insurance exist. Objectives: The aim of this study was to explore the health economic burden in women with CIN diagnoses who either underwent cervical conization or were managed conservatively. Methods: We conducted a retrospective claims data analysis using the InGef Research Database from 2013 to 2018. Healthcare costs and resource utilization in a 24-month observation period (1:1:1 matching) were compared in 18- to 45-year-old women with CIN (1-3) who underwent a conization procedure (study cohort 1) and in women with CIN (1-3) who did not undergo conization (study cohort 2) to women with neither CIN nor conization (control group). Results: For each group, 2749 women were identified. Mean total healthcare costs after 24 months were higher in study cohort 1 (€4446, P<.01) and study cohort 2 (€3754, P=.09) compared with the control group (€3426). Comparing study cohort 1 and 2 to controls, mean differences were highest in age groups 41-45 years (cohort 1: €5115 vs €3354, P<.01; cohort 2: €4152 vs €3354, P=.14). Significantly more women were hospitalized at least once in study cohort 1 (57.46%, P<.01) and study cohort 2 (38.74%, P<.01) compared with the control group (31.14%). Frequency of outpatient physician visits was significantly higher in both study cohorts (43.23 visits, P<.01 and 38.60 visits, P<.01) compared with the control group (32.07 visits). Conclusion: Our results revealed 30% and 10% increased total healthcare costs in women with CIN undergoing invasive treatment (study cohort 1) and conservative management (study cohort 2), respectively, compared with a control group of women with no CIN in a 2-year follow-up period.

Burden of CIN2+ diagnoses and conizations in women aged 18-45 years-a retrospective secondary data analysis of German statutory health insurance claims data

Purpose

High grade cervical intraepithelial neoplasia (CIN2+) may progress to cervical cancer. They may be detected by screening and are usually treated by conization. This study aimed at assessing annual proportions of screening, prevalent and incident CIN2+ diagnoses, as well as proportions of (re-)conizations during 24 months follow-up after conization in Germany.

Methods

A descriptive retrospective claims data analysis of the years 2013–2018 was conducted using the InGef Research Database. Women aged 18–45 years with CIN2+ diagnoses were identified by ICD-10-GM codes (N87.1, N87.2, D06.-, and C53.-). Cervical conizations were identified by OPS codes (5–671.0* or 5–671.1*). Screening participation was identified by EBM codes (01730, 01733, 32819 or 32820). Annual proportions were calculated as women with the respective documented codes divided by all women in the respective age group per calendar year.

Results

Overall annual proportions of screened women spanned from 60.01 to 61.33% between 2013 and 2018. The overall annual prevalence of CIN2+ diagnoses (regardless of screening participation) ranged from 0.72 to 0.84% between 2013 and 2018, with highest proportions observed in women aged 27–45 years. Also, CIN2+ incidence was highest in women 27–45 years. Annual proportion of women undergoing conization was 0.24% in 2013 and 0.21% in 2018. During a 24-month follow-up period after conization, 2.91% of women underwent a re-conization 3 months or later after the initial conization.

Conclusion

This analysis demonstrates a considerable burden of CIN2+, conizations and re-conizations in Germany, especially in women aged 27–45 years. This highlights the need for intensified prevention efforts such as expanding human papillomavirus (HPV) vaccination.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-022-06548-7.

Risikobewertung von Zytologiebefunden im Zervixkarzinom-Screening

Zielstellung

Das CIN2+-/CIN3+(zervikale intraepitheliale Neoplasie)-Risiko plattenepithelialer zytologischer Befunde (Gruppe II‑p, IIID1, III‑p, IIID2 der Münchner Nomenklatur [MN] III) soll bewertet und mit Empfehlungen für das Patienten-Management korreliert werden.

Material und Methoden

Alle 4321 Frauen mit einer Gruppe II‑p, IIID1, III‑p, IIID2, IVa‑p, IVb-p und V‑p von Januar 2014 bis Dezember 2016 wurden in einer Praxis für Pathologie erfasst. Zytologische Vorbefunde, alle zytologischen und histologischen Folgebefunde bis Juli 2019 wurden dokumentiert. Für die Erstbefunde wurde pro Befundgruppe mittels Kaplan-Meier-Schätzung das Risiko für CIN2+/CIN3+ ermittelt. Das Risiko bei persistierenden Befunden und der Einfluss des Alters wurden untersucht.

Ergebnisse

Für die Erstbefunde der Gruppen II‑p, IIID1, III‑p und IIID2 beträgt das Risiko für CIN2+ nach 12, 24 und 60 Monaten 1,0/3,3/11,8; 3,1/9,4/22,7; 33,4/38,4/55,5 bzw. 35,1/46,2/64,4 (%). Das Risiko für CIN3+ beträgt für die gleichen Zeiträume 0,6/2,7/9,7; 1,9/5,2/14,3; 28,8/32,4/44,0 bzw. 28,5/36,7/52,4 (%). Bei persistierenden Befunden derselben Gruppe steigt das Risiko für CIN2+ und CIN3+ signifikant vom ersten zum zweiten II-p‑, IIID1-, III-p- und IIID2-Befund. Bei den Gruppen II‑p, IIID1 und IIID2 finden sich keine signifikanten Altersunterschiede, bei III-p-Befunden ist das Risiko für Frauen <30 und <35 signifikant größer als für ältere Frauen.

Schlussfolgerung

Die MN III mit 3‑gliedriger Dysplasiegraduierung klassifiziert die zytologischen Befunde risikoorientiert. Ihre Befundgruppen eignen sich als Basis für ein risikoadaptiertes Management, um insbesondere Überdiagnostik und -therapie zu vermeiden.