Decline in Cervical Cancer Incidence and Mortality in New South Wales in Relation to Control Activities (Australia)

The socioeconomic gradient in mortality from ovarian, cervical, and endometrial cancer in Australian women, 2001-2018: A population-based study

BACKGROUND

Socio-economic (SE) status is closely linked to health status and the mechanisms of this association are complex. One important adverse effect of SE disadvantage is vulnerability to cancer and cancer is a major cause of morbidity and mortality in Australia.

AIMS

We aimed to estimate the effect of SE status on mortality rates from ovarian, cervical, and endometrial cancer.

MATERIALS AND METHODS

National mortality data were obtained from the Australian Bureau of Statistics (ABS) for the calendar years from 2001 to 2018, inclusive. Individual deaths were grouped by the ABS Index of Relative Socio-economic Advantage and Disadvantage. Population data were obtained to provided denominators allowing calculation of mortality rates (deaths per 100 000 women aged 30-79 years). Statistical analyses performed included tabulating point-estimates of mortality rates and their changes over time and modelling the trends of rates using maximum likelihood method.

RESULTS

Age-standardised mortality rates for ovarian and cervical cancer fell over the study period but increased for endometrial cancer. There was clear evidence of a SE gradient in the mortality rate for all three cancers. This SE gradient increased over the study period for ovarian and cervical cancer but remained unchanged for endometrial cancer.

CONCLUSIONS

Women at greater SE disadvantage have higher rates of death from the commonest gynaecological cancers and this gradient has not reduced over the last two decades. After the COVID-19 pandemic efforts must be redoubled to ensure that Australians already at risk of ill health do not face even greater risks because of their circumstances.

Global cervical cancer research: A scientometric density equalizing mapping and socioeconomic analysis

Cervical cancer has caused substantial morbidity and mortality for millions of women over the past decades. While enormous progress has been made in diagnosis, prevention and therapy, the disease is still fatal for many women—especially in low-income countries. Since no detailed studies are available on the worldwide research landscape, we here investigated the global scientific output related to this cancer type by an established protocol. The “New Quality and Quantity Indices in Science” platform assessed all relevant cervical cancer research published in the Web of Science since 1900. A detailed analysis was conducted including country-specific research productivity, indicators for scientific quality, and relation of research activity to socioeconomic and epidemiologic figures. Visualization of data was generated by the use of density equalizing map projections. Our approach identified 22,185 articles specifically related to cervical cancer. From a global viewpoint, the United States of America was the dominating country in absolute numbers, being followed by China and Japan. By contrast, the European countries Sweden, Austria, and Norway were positioned first when the research activity was related to the population number. When the scientific productivity was related to annual cervical cancer cases, Scandinavian countries (Finland #1, Sweden #4, Norway #5, Denmark #7), the Alpine countries Austria (#2) and Switzerland (#6), and the Netherlands (#3) were leading the field. Density equalizing mapping visualized that large parts of Africa and South America were almost invisible regarding the global participation in cervical cancer research. Our data documented that worldwide cervical cancer research activity is continuously increasing but is imbalanced from a global viewpoint. Also, the study indicated that global and public health aspects should be strengthened in cervical carcinoma research in order to empower more countries to take part in international research activities.

Barriers affecting uptake of cervical cancer screening in low and middle income countries: A systematic review

BACKGROUND

Cervical cancer is the second-most common cancer among women in the developing world and approximately 500,000 cases are diagnosed each year. In developed countries, cervical cancer (CCa) accounts for only 3.6% of newly diagnosed cancers.

OBJECTIVE

The present study aims to identify the most effective barriers associated with CCa screening uptake in low and middle-income countries (L and MICs) and aid to adopt effective measures to overcome prevailing barriers to the attainment of CCa uptake in the community.

MATERIALS AND METHODS

Health sciences electronic databases like MEDLINE, PubMed, Cochrane library, and Google Scholar were searched for studies published until August 2017. Keywords used for the search were ("cervical cancer screening"), ("barriers"), AND ("low income countries" OR "Middle income countries"). Articles were reviewed and data were extracted by using Mendeley Desktop Software (V-1.17.10). Income-level classification of countries was done as per the World Bank 2017 report. Statistical software like SPSS-V.23 and Medical-V.14 were used for the statistical application.

RESULTS

A total of 31 studies met the inclusion criteria with a total of 25,650 participants. The sample size of the included studies ranged from 97 to 5929 participants. Articles majorly reported data on participants from African region (51.6%) and minimally in the Western Pacific region (3.2%). Sampling methods among studies varied from convenience sampling-12 (39.7%) to consecutive sampling-1 (3.2%). Besides, two studies (6.5%) did not discuss their sampling procedures. It was observed that "Lack of information about CCa and its treatment" (Barrier of lack of knowledge and Awareness); "Embracement or shy" (Psychological Barrier); "Lack of time" (structural Barrier); and "Lack of family support" (Sociocultural and religious barrier) were the most commonly reported among all 22 barriers.

CONCLUSION

There is a need of policies advancement of CCa screening programs by focusing on aspects of accessibility, affordability, CCa education, and the necessity of screening to improve screening uptake to control the CCa morbidity and mortality rate in L and MIC's.

Participation in Cervical Screening by Self-collection, Pap, or a Choice of Either in Brazil

Most cervical cancers occur in women who do not participate in cervical-cancer screening. We therefore evaluated adherence to screening for clinic-based Pap testing, self-collected sampling for HPV testing, and choice of the 2 among 483 unscreened/underscreened women in Brazil. Three public Basic Health Units (BHU) were each randomly assigned to three arms: (i) Pap testing at the BHU (N = 160), (ii) "Self&HPV" (self-collection for HPV testing) (N = 161), and (iii) "Choice" between self-collection and HPV testing and Pap test at the local BHU (N = 162). The theory-based (PEN-3 and Health Belief Model) intervention in all three arms was implemented by trained Community Health Workers (CHW) at participants' home. With the first invitation, 60.0% in the Pap arm, 95.1% [154 of 161 (95.7%) who selected Self&HPV and 0 of 1 (0.0%) who selected Pap] in the Choice arm, and 100% in the Self&HPV arm completed screening. By the second invitation to choose a method of screening in the Choice arm, 100% completed screening. After three invitations, 75.0% of women in the Pap arm completed screening. Adherence to screening differed by study arm (P < 0.001). In conclusion, Self&HPV testing is a promising strategy for unscreened/underscreened women who are recalcitrant or unable to undergo clinic-based cervical screening to complement the screening modality used in the general population. In Brazil, where Pap testing is recommended for routine cervical screening, training CHWs in behavior change strategies and offering Self&HPV or Choice could greatly improve screening population coverage by reaching the unscreened/underscreened populations.

Cervical precancerous changes and selected cervical microbial infections, Kiambu County, Kenya, 2014: a cross sectional study

BACKGROUND

Cervical cancer is the predominant cancer among women in Kenya and second most common in women in developing regions. Population-based cytological screening and early treatment reduces morbidity and mortality associated with the cancer. We determined the occurrence of cervical precancerous changes and cervical microbial infections (Trichomonas vaginalis, Candida albicans, Neisseria gonorrhea and Actinomyces) among women attending Family Health Option Kenya (FHOK) clinic in Thika.

METHODS

This was a hospital based cross sectional study among women attending reproductive health screening clinic from November 2013 to January 2014. Cervical Intraepithelial Neoplasia (CIN) I, II, III, cervical cancer and microbial infection (Actinomyces, Trichomonas vaginalis and Yeast cells) diagnosis was based on Pap smear screening test and High Vaginal Swab wet preparation microscopy. Neisseria gonorrhea was diagnosed through Gram staining. Socio-demographic and reproductive health data was collected using a structured questionnaire administered to the study participants and analyzed using Epi Info version 3.5.1.

RESULTS

Of the 244 women screened, 238 (97.5%) presented with cervical inflammation, 80 (32.8%) cervical microbial infections and 12 (4.9%) cervical precancerous changes; 10 (83.3%) with CIN I and 2 (16.7%) CIN II. Of the 80 cervical microbial infections, 62 (77.5%) were yeast cell and 18 (22.5%) T. vaginalis. One thirty four (55%) participants had no history of Pap smear screening of which 84 (62.7%) were 20-40 years. Use of IUCDs (OR: 2.47, 95% CI 1.3-4.6) was associated with cervical inflammation.

CONCLUSIONS

CIN I was the predominant cervical precancerous change. There is need to scale up cervical screening test to capture all categories of women.

Changes in cervical cancer incidence following the introduction of organized screening in Italy

OBJECTIVE

To quantify the impact of organized cervical screening programs (OCSPs) on the incidence of invasive cervical cancer (ICC), comparing rates before and after activation of OCSPs.

METHODS

This population-based investigation, using individual data from cancer registries and OCSPs, included 3557 women diagnosed with ICC at age 25-74years in 1995-2008. The year of full-activation of each OCSP was defined as the year when at least 40% of target women had been invited. Incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs) were calculated as the ratios between age-standardized incidence rates observed in periods after full-activation of OCSPs vs those observed in the preceding quinquennium.

RESULTS

ICC incidence rates diminished with time since OCSPs full-activation: after 6-8years, the IRR was 0.75 (95% CI: 0.67-0.85). The reduction was higher for stages IB-IV (IRR=0.68, 95% CI: 0.58-0.80), squamous cell ICCs (IRR=0.74, 95% CI: 0.64-0.84), and particularly evident among women aged 45-74years. Conversely, incidence rates of micro-invasive (stage IA) ICCs increased, though not significantly, among women aged 25-44years (IRR=1.34, 95% CI: 0.91-1.96). Following full-activation of OCSPs, micro-invasive ICCs were mainly and increasingly diagnosed within OCSPs (up to 72%).

CONCLUSION(S)

Within few years from activation, organized screening positively impacted the already low ICC incidence in Italy and favored down-staging.

Factors associated with the uptake of cervical cancer screening among women in portland, Jamaica

BACKGROUND

Cervical cancer is the second most common cancer among women worldwide and is the leading cause of deaths in developing countries. Despite the strong evidence that cervical cancer screening results in decreased mortality from this disease, the uptake for cervical screening among Jamaican women remains low.

AIMS

This study was carried out to identify factors associated with Jamaican women's decisions to screen for cervical cancer.

MATERIALS AND METHODS

Cross-sectional descriptive study of 403 women aged 19 years and older from Portland, Jamaica. An interviewer-administered questionnaire assessed the women's cervical cancer screening history, as well as their knowledge, attitudes, and practices regarding the disease and screening.

RESULTS

Of the 403 women interviewed, 66% had a Papanicolaou (Pap) smear and only 16% had a Pap test within the past year. Significant predicators of uptake of screening were being married, age, parity, discussing cancer with health provider, perception of consequences of not having a Pap smear, and knowing a person with cervical cancer. Women who did not know where to go for a Pap smear were 85% less likely to have been screened (prevalence odds ratio (POR): 0.15, 95% confidence interval (CI): 0.04, 0.52).

CONCLUSIONS

This study showed suboptimal uptake of cervical cancer screening among Jamaican women. Multipronged approaches are needed to address barriers to screening, as well as identify and support conditions that encourage women's use of reproductive health services, thereby reducing incidence and mortality rates from cervical cancer.

Socioeconomic disparity in cervical cancer screening among Korean women: 1998-2010

Background

Cervical cancer is the sixth most common cause of cancer among Korean women and is one of the most preventable cancers in the world. This study aimed to investigate the change in cervical cancer screening rates, the level of socioeconomic disparities in cervical cancer screening participation, and whether there was a reduction in these disparities between 1998 and 2010.

Methods

Using the Korean Health and Nutrition Examination Survey, women 30 years or older without a history of cervical cancer and who completed a health questionnaire, physical examination, and nutritional survey were included (n = 17,105). Information about participation in cervical cancer screening was collected using a self-administered questionnaire. Multiple logistic regression analysis was performed to investigate the relationship between cervical cancer screening participation and the socioeconomic status of the women.

Results

The cervical cancer screening rate increased from 40.5% in 1998 to 52.5% in 2010. Socioeconomic disparities influenced participation, and women with lower educational levels and lower household income were less likely to be screened. Compared with the lowest educational level, the adjusted odds ratios (ORs) for screening in women with the highest educational level were 1.56 (95% confidence interval (CI): 1.05–2.30) in 1998, and 1.44 (95% CI: 1.12–1.87) in 2010. Compared with women with the lowest household income level, the adjusted ORs for screening in women with the highest household income level were 1.80 (95% CI: 1.22–2.68), 2.82 (95% CI: 2.01–3.96), and 1.45 (95% CI: 1.08–1.94) in 2001, 2005, and 2010, respectively.

Conclusion

Although population-wide progress has been made in participation in cervical cancer screening over the 12-year period, socioeconomic status remained an important factor in reducing compliance with cancer screening.

Evidence for cervical cancer mortality with screening program in Taiwan, 1981-2010: age-period-cohort model

Background

Cervical cancer is the most common cancer experienced by women worldwide; however, screening techniques are very effective for reducing the risk of death. The national cervical cancer screening program was implemented in Taiwan in 1995. The objective of this study was to examine and provide evidence of the cervical cancer mortality trends for the periods before and after the screening program was implemented.

Methods

Data from 1981 to 2010 of the causes of death registered were obtained from the Department of Health, Taiwan. Age-standardized mortality rates, age-specific rates, and age-period-cohort models that employed the sequential method were used to assess temporal changes that occurred between 1981 and 2010, with 1995 used as the separating year.

Results

The results showed that for both time periods of 1981 to 1995 and 1996 to 2010, age and period had significant effects, whereas the birth cohort effects were insignificant. For patients between 80 and 84 years of age, the mortality rate for 1981 to 1995 and 1996 to 2010 was 48.34 and 68.08. The cervical cancer mortality rate for 1996 to 2010 was 1.0 for patients between 75 and 79 years of age and 1.4 for patients between 80 and 84 years of age compared to that for 1981 to 1995. Regarding the period effect, the mortality trend decreased 2-fold from 1996 to 2010.

Conclusions

The results of this study indicate a decline in cervical cancer mortality trends after the screening program involving Papanicolaou tests was implemented in 1995. However, the positive effects of the screening program were not observed in elderly women because of treatment delays during the initial implementation of the screening program.

Impact of organised cervical screening on cervical cancer incidence and mortality in migrant women in Australia

Background

Organised cervical screening, introduced in 1991, appears to have reduced rates of cervical cancer incidence and mortality in women in Australia. This study aimed to assess whether cervical cancer rates in migrant women in the state of New South Wales (NSW) showed a similar pattern of change to that in Australian-born women after 1991.

Methods

Data from the NSW Central Cancer Registry were obtained for females 15+ years diagnosed with invasive cervical cancer from 1973 to 2008 (N=11,485). We used joinpoint regression to assess annual percent changes (APC) in cervical cancer incidence and mortality before and after the introduction of organised cervical screening in 1991.

Results

APC in incidence fell more rapidly after than before 1991 (p<0.001) amongst women from seven groups defined by country of birth (including Australia). There was only weak evidence that the magnitude of this incidence change varied by country-of-birth (p=0.088). The change in APC in mortality after 1991, however, was heterogeneous by country of birth (p=0.004). For Australian and UK or Ireland-born women the mortality APC fell more rapidly after 1991 than before (p=0.002 and p=0.001 respectively), as it did for New Zealand, Middle East, North Africa and Asian-born (p≥0.05), but in other European-born and women from the ’Rest of the World’ it appeared to rise (p=0.40 and p=0.013 respectively).

Conclusions

Like Australian-born women, most, but not all, groups of migrant women experienced an increased rate of fall in incidence of cervical cancer following introduction of organised cervical screening in 1991. An apparent rise in mortality in women in a ‘Rest of the World’ category might be explained by a recent rise in migration from countries with high cervical cancer incidence and mortality rates.

Lower utilization of cervical cancer screening by nurses in Taiwan: a nationwide population-based study

OBJECTIVE

Using a nationwide population-based database in Taiwan, this study compares use of Pap smear testing by nurses and the general population.

METHOD

We compared 1093 practicing female nurses and 5465 randomly selected female patients from the 2006 National Health Insurance (NHI) database to evaluate the likelihood of receiving at least one Pap smear during a three-year period.

RESULTS

We found that 48.9% of the nurses and 56.2% of comparison subjects received a Pap test from 2004 to 2006 in Taiwan. Regression analysis showed that practicing female nurses were less likely to receive a Pap smear compared with the general population (OR=0.42, 95% CI=0.35-0.50, p<0.001), after adjusting for monthly incomes, number of ob/gyn ambulatory care visits, urbanization level and the geographic location of the communities where subjects resided.

CONCLUSION

Nurses were less likely to undergo cervical screening than the general population, despite ease of access and a national health insurance system providing universal coverage to residents of Taiwan. Efforts to raise the Pap screening rate among nurses may require addressing unique cultural and occupational concerns.

Cytology and cervical cancer surveillance in an era of human papillomavirus vaccination

Cytological and cancer surveillance will provide the most effective indications of short-term effects and long-term outcomes of the introduction of the human papillomavirus (HPV) vaccine in Australia. This article outlines how this surveillance is proposed to occur through the established national monitoring mechanisms of the National Cervical Screening Program in the annual Australian Institute of Health and Welfare (AIHW) publication 'Cervical screening in Australia'. Cytological surveillance will be possible principally through cytology data provided annually by the state and territory cervical cytology registers, and it is expected that these data will provide the earliest and most comprehensive indications of effects from the HPV vaccine. Some potential issues in interpreting these data are also discussed, including the potentially confounding effects of the introduction of new National Health and Medical Research Council guidelines 'Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen-detected abnormalities' some 9 months before the introduction of the vaccine. Cancer surveillance over the long term will be possible using cervical cancer incidence data reported annually for the National Cervical Screening Program in 'Cervical screening in Australia' using data sourced from the Australian Cancer Database. In a final discourse, the HPV vaccine and cervical screening are discussed concurrently, and the importance of continued cervical screening in the HPV vaccine era emphasised.

Disparities in cancer screening: acceptance of Pap smears among homeless women

AIMS

Cervical cancer is a preventable disease through screening and early treatment. Rates of cervical cancer are higher in impoverished women, including homeless women. This study assessed the acceptance of free and accessible Pap smears offered to homeless women in a respite care setting.

METHODS

A convenience sample of 205 adult women receiving respite care at a facility for homeless people in Boston, Massachusetts, between 2004 and 2007 were offered screening for cervical cancer during routine encounters with the medical staff during their stay. Rates of acceptance of screening as well as medical and sociodemographic information were collected on the women.

RESULTS

Of 205 women enrolled in the study, 129 (63%) were in need of screening and offered a Pap smear; 80 (62%) accepted and 49 (38%) declined. Of those who agreed to be tested, 56 (70%) had a Pap smear performed, resulting in 10 (18%) atypical results (atypical squamous cells of undetermined significance [ASCUS] or low-grade squamous intraepithelial lesion [LGSIL]) and 15 (27%) benign findings needing follow-up (e.g., vaginitis without evidence of malignancy).

CONCLUSIONS

A large proportion of homeless women receiving respite care decline a free Pap smear despite being in medical need of cervical cancer screening. Access and cost may not be the only barriers to screening among homeless women, and new and innovative approaches to screening in vulnerable populations need to be investigated in order to close the disparity gap.

Are adjunctive markers useful in routine cervical cancer screening? Application of p16(INK4a) and HPV-PCR on ThinPrep samples with histological follow-up

The objectives of the study were to evaluate 1) the diagnostic sensitivity and specificity of p16(INK4a) as a marker for high-grade cervical lesions, 2) the results of a real-time polymerase chain reaction detecting high-risk human papillomavirus, and 3) the interobserver variability of the p16(INK4a) interpretation.A total of 232 ThinPrep samples were stained for p16(INK4a), and HPV-DNA PCR was performed on 107 specimens with inclusion of both benign and abnormal cytology. Histological follow-up information was collected. The diagnostic sensitivity of ASC+ with CIN2+ in histology as endpoint was 96% for p16(INK4a) and 100% for HR-HPV DNA PCR, and the diagnostic specificity was 41% and 27%, respectively. If p16(INK4a) had been used for triage of the ASC samples, then 18 patients (42%) could have been spared unnecessary follow-up procedures compared to six patients (21%) with the HR-HPV DNA test.

High-grade cervical abnormalities and screening intervals in New South Wales, Australia

OBJECTIVES

This study aims to determine the association of two versus three year screening intervals with the likelihood of detection of a high-grade cervical abnormality and cervical cancer.

METHODS

Data were obtained from the New South Wales (NSW) Papanicolaou (Pap) Test Register (PTR) and NSW Central Cancer Registry (CCR). Subjects were human papillomavirus (HPV) unvaccinated women aged 20-69 years who had a minimum of two Pap tests with a negative result at their first recorded Pap test (n = 1,213,295). Logistic regression was used to determine the association between screening interval and the likelihood of: (1) a cytological prediction of high-grade abnormality, defined as cervical intraepithelial neoplasia (CIN) 2 or greater; (2) a histologically confirmed high-grade abnormality; (3) a cytological prediction of cervical cancer and (4) a confirmed diagnosis of cervical cancer, controlling for potential confounders of age and socioeconomic status (SES) of area of residence.

RESULTS

For each year increase in the screening interval, the odds of a histologically confirmed high-grade abnormality increased significantly in women aged 20-29 years (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.20-1.28) and in women aged 30-49 years (OR 1.11, 95% CI 1.06-1.16), but not in women aged 50-69 years (OR 1.08, 95% CI 0.89-1.32). Similar results were observed for cytologically detected high-grade abnormalities. The screening interval was significantly and positively associated with a cytological prediction of cervical cancer (OR 1.40, 95% CI 1.28-1.54) and a confirmed cervical cancer diagnosis (OR 1.66, 95% CI 1.33-2.07) in women aged 20-69 years. Despite the higher risks, we estimate that if the screening interval were increased from two to three years, and the number of women participating in treatment screening was the same as for biennial screening in NSW, then 140 (95% CI 60-220) fewer high-grade cytology results would occur per year, and there would be around 19 (95% CI -50- 89) fewer high-grade cases confirmed by histology. As the 95% CI covers zero in the latter estimate, there is no significant difference in expected confirmed high-grade abnormalities between biennial and triennial screening if the same number of women are screened triennally as biennially. [corrected] Equivalently, 2.3 (95% CI 1.8-2.8) and 1.9 (95% CI 1.5-2.4) extra cases of high-grade cytology and histology, respectively, would be expected per 1000 women with initially negative cytology if the screening interval were extended from two to three years.

CONCLUSION

Increasing the cervical screening interval from two to three years would be expected to significantly increase the odds of detection of a high-grade abnormality for NSW women aged 20-49 years and cervical cancer for NSW women aged 20-69 years. Accordingly, our study provides evidence in support of retaining the recommended cervical screening interval at two years for HPV unvaccinated, well women.

Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia

An assessment of recent data on cancer in Indigenous Australians (Aborigines and Torres Strait Islanders) shows that, although they are less likely to have some types of cancer than other Australians, Indigenous people are significantly more likely to have cancers that have a poor prognosis, but are largely preventable, such as lung and liver cancer. Indigenous people with cancer are diagnosed at a later stage, are less likely to receive adequate treatment, and are more likely to die from their cancers than other Australians. Inadequate identification of Indigenous people in cancer registers precludes reporting for some parts of Australia, but sufficient information is available to identify priorities and inform appropriate remedial action. Health-risk factors, especially smoking, and inadequate health-system performance largely explain the patterns of cancer incidence and mortality in areas with adequate data. Effective tobacco control programmes, improvements across a range of health services, and meaningful Indigenous engagement are all needed to decrease the burden of cancer in Indigenous Australians.

Prognostic value of histopathology and trends in cervical cancer: a SEER population study

BACKGROUND

Histopathology is a cornerstone in the diagnosis of cervical cancer but the prognostic value is controversial.

METHODS

Women under active follow-up for histologically confirmed primary invasive cervical cancer were selected from the United States Surveillance, Epidemiology, and End Results (SEER) 9-registries public use data 1973-2002. Only histologies with at least 100 cases were retained. Registry area, age, marital status, race, year of diagnosis, tumor histology, grade, stage, tumor size, number of positive nodes, number of examined nodes, odds of nodal involvement, extent of surgery, and radiotherapy were evaluated in Cox models by stepwise selection using the Akaike Information Criteria.

RESULTS

There were 30,989 records evaluable. From 1973 to 2002, number of cases dropped from 1,100 new cases/year to 900/year, but adenocarcinomas and adenosquamous carcinoma increased from 100/year to 235/year. Median age was 48 years. Statistically significant variables for both overall and cause-specific mortality were: age, year of diagnosis, race, stage, histology, grade, hysterectomy, radiotherapy, tumor size and nodal ratio. The histological types were jointly significant, P < 0.001. Cause-specific mortality hazard ratios by histological type relatively to non-microinvasive squamous cell carcinoma were: microinvasive squamous cell carcinoma 0.28 (95% confidence interval: 0.20-0.39), carcinoma not otherwise specified 0.91 (0.79-1.04), non-mucinous adenocarcinoma 1.06 (0.98-1.15), adenosquamous carcinoma 1.35 (1.20-1.51), mucinous adenocarcinoma 1.52 (1.23-1.88), small cell carcinoma 1.94 (1.58-2.39).

CONCLUSION

Small cell carcinoma and adenocarcinomas were associated with poorer survival. The incidental observation of increasing numbers of adenocarcinomas despite a general decline suggests the inefficiency of conventional screening for these tumors. Increased incidence of adenocarcinomas, their adverse prognosis, and the young age at diagnosis indicate the need to identify women who are at risk.

Cervical cancer in Australia and the United Kingdom: comparison of screening policy and uptake, and cancer incidence and mortality

OBJECTIVE

To compare cervical screening policy, screening uptake, and changes in cervical cancer incidence and mortality between Australia and the United Kingdom.

DESIGN

Analysis of screening registry data and national cancer statistics.

SETTING

In Australia, organised cervical screening was initiated in 1991 for sexually active women aged 18-69 years, with a recommended 2-yearly interval. In the UK, organised screening began in 1988 for women aged 20-64 years, with a recommended 3-yearly interval in most regions.

RESULTS

Estimated lifetime screening participation rates in 2001 were similar in the two countries, at 88% in Australia and 90% in the UK. For women who were screened and had a negative result, the median time to the next screen was 27 months in Australia and 38 months in the UK. At 39 months, equivalent proportions (74%) had been re-screened in the two countries, and by 60 months the re-screened proportions were 81% in Australia and 94% in the UK. From 1991-1993 to 1998-2000, the incidence of cervical cancer in women aged 20-69 years fell by 33% in Australia and 33% in the UK, and mortality from cervical cancer fell by 36% in both countries.

CONCLUSIONS

After the introduction of organised screening, similar reductions in cervical cancer incidence and mortality were achieved in Australia and the UK. Therefore, the 2-yearly screening policy in Australia and the predominantly 3-yearly screening policy in the UK appear to have been of broadly similar effectiveness.

Avoidable mortality across Canada from 1975 to 1999

BACKGROUND

The concept of 'avoidable' mortality (AM) has been proposed as a performance measure of health care systems. In this study we examined mortality in five geographic regions of Canada from 1975 to 1999 for previously defined avoidable disease groups that are amenable to medical care and public health. These trends were compared to mortality from other causes.

METHODS

National and regional age-standardized mortality rates for ages less than 65 years were estimated for avoidable and other causes of death for consecutive periods (1975-1979, 1980-1985, 1985-1989, 1990-1994, and 1995-1999). The proportion of all-cause mortality attributable to avoidable causes was also determined.

RESULTS

From 1975-1979 to 1995-1999, the AM decrease (46.9%) was more pronounced compared to mortality from other causes (24.9%). There were persistent regional AM differences, with consistently lower AM in Ontario and British Columbia compared to the Atlantic, Quebec, and Prairies regions. This trend was not apparent when mortality from other causes was examined. Injuries, ischaemic heart disease, and lung cancer strongly influenced the overall AM trends.

CONCLUSION

The regional differences in mortality for ages less than 65 years was attributable to causes of death amenable to medical care and public health, especially from causes responsive to public health.