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Bergstein A, Huang Y, Hershman DL, Xu X, Wright J. Impact of medicaid expansion on cervical cancer screening: A state-specific difference in difference analysis. Gynecol Oncol 2024; 189:49-55. [PMID: 39013240 DOI: 10.1016/j.ygyno.2024.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/24/2024] [Accepted: 06/30/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE In 2014 the Affordable Care Act expanded Medicaid coverage in states that opted to participate. Limited data are available describing the effect of Medicaid expansion on cancer screening. The objective of our study was to evaluate trends in cervical cancer screening associated with Medicaid expansion. METHODS Using data from the Behavioral Risk Factor Surveillance System, we identified female respondents ages 30-64 years with a household income below $35,000. The outcome measure was guideline-adherent cervical cancer screening. The years 2010 and 2012 constituted the pre-expansion period while 2016 and 2018 were used to capture the post-expansion period. A difference-in-difference (DID) analysis was performed to assess changes in cervical cancer screening in Medicaid expansion states compared to non-expansion states, for the overall sample and for each expansion state individually. RESULTS The overall DID analysis showed a greater increase in cervical cancer screening by 1.1 percentage points (95% CI: 0.1 to 2.0%, P = 0.03) in expansion states compared to non-expansion states. The analysis comparing individual expansion states to non-expansion states showed that 6 expansion states had a significantly higher increase in screening relative to non-expansion states: Oregon (8.5%, P < 0.001), Kentucky (4.5%, P = 0.001), Washington (4.2%, P = 0.002), Colorado (4.3%, P = 0.008), Nevada (4.7%, P = 0.048), and Ohio (2.8%, P = 0.03). Of these states, 5 ranked among the states with the lowest baseline screening rates. CONCLUSIONS Medicaid expansion states experienced a greater increase in cervical cancer screening relative to non-expansion states. Expansion states with lower baseline screening rates experienced greater increases in screening after expanding Medicaid.
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Affiliation(s)
- Adrianna Bergstein
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Dawn L Hershman
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, New York, NY, USA; New York-Presbyterian Hospital, New York, NY, USA
| | - Xiao Xu
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America
| | - Jason Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States of America; Herbert Irving Comprehensive Cancer Center, New York, NY, USA; New York-Presbyterian Hospital, New York, NY, USA.
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Kultalahti H, Heinävaara S, Sarkeala T, Pankakoski M. Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study. CANCER RESEARCH COMMUNICATIONS 2023; 3:1823-1829. [PMID: 37700796 PMCID: PMC10494786 DOI: 10.1158/2767-9764.crc-23-0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages. Significance To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.
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Affiliation(s)
- Henric Kultalahti
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sirpa Heinävaara
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Maiju Pankakoski
- Finnish Cancer Registry, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Tranberg M, Petersen LK, Hammer A, Elfström M, Blaakær J, Jørgensen SF, Bennetsen MH, Jensen JS, Andersen B. Value of a catch-up HPV test in women aged 65 and above: A Danish population-based nonrandomized intervention study. PLoS Med 2023; 20:e1004253. [PMID: 37410699 PMCID: PMC10325045 DOI: 10.1371/journal.pmed.1004253] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/31/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus (HPV) test is replacing cytology as the primary cervical cancer screening test due to superior sensitivity, but in most countries women ≥65 years have never had an HPV test despite they account for around 50% of cervical cancer deaths. We explored the effect of a catch-up HPV test among 65- to 69-year-old women without previous record of HPV-based screening. METHODS AND FINDINGS This population-based nonrandomized intervention study (quasi-experimental design) included Danish women aged 65 to 69 with no record of cervical cancer screening in the last ≥5.5 years and no HPV-exit test at age 60 to 64 at the time of study inclusion. Eligible women residing in the Central Denmark Region were invited for HPV screening either by attending clinician-based sampling or requesting a vaginal self-sampling kit (intervention group, n = 11,192). Women residing in the remaining four Danish regions received standard care which was the opportunity to have a cervical cytology collected for whatever reason (reference group, n = 33,387). Main outcome measures were detection of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) per 1,000 women eligible for the screening offer and the benefit-harm ratio of the intervention and standard practice measured as the number of colposcopies needed to detect one CIN2+ case. The minimum follow-up time was 13 months for all tested women (range: 13 to 25 months). In the intervention group, 6,965 (62.2%) were screened within 12 months from the date of study inclusion and 743 (2.2%) women had a cervical cytology collected in the reference group. The CIN2+ detection was significantly higher in the intervention group (3.9, 95% confidence interval (CI): [2.9, 5.3]; p < 0.001; n = 44/11,192) as compared to the reference group (0.3, 95% CI: [0.2, 0.6]; n = 11/33,387). For the benefit-harm ratio, 11.6 (95% CI: [8.5, 15.8]; p = 0.69; n = 511/44) colposcopies were performed to detect one CIN2+ in the intervention group as compared to 10.1 (95% CI: [5.4, 18.8]; n = 111/11) colposcopies in the reference group. The study design entails a risk of confounding due to the lack of randomization. CONCLUSIONS The higher CIN2+ detection per 1,000 eligible women in the intervention group supports that a catch-up HPV test could potentially improve cervical cancer prevention in older women. This study informs the current scientific debate as to whether women aged 65 and above should be offered a catch-up HPV test if they never had an HPV test. TRIAL REGISTRATION ClinicalTrials.gov NCT04114968.
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Affiliation(s)
- Mette Tranberg
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, Southern University of Denmark, Odense, Denmark
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Gødstrup Hospital, Herning, Denmark
| | - Miriam Elfström
- Center for Cervical Cancer Prevention, Karolinska University Hospital, Stockholm, Sweden
- Regional Cancer Center of Stockholm-Gotland, Stockholm, Sweden
| | - Jan Blaakær
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Susanne Fogh Jørgensen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | | | - Jørgen Skov Jensen
- Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- University Research Clinic for Cancer Screening, Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Firtina Tuncer S, Tuncer HA. Cervical Cancer Screening in Women Aged Older Than 65 Years. J Low Genit Tract Dis 2023; 27:207-211. [PMID: 37097226 DOI: 10.1097/lgt.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
OBJECTIVES Considerable debate exists among guidelines regarding when cervical cancer screening can be safely stopped. The authors aimed to compare the efficiency of human papillomavirus (HPV) test, cytology, and previous screening history for the diagnosis of cervical intraepithelial neoplasia (CIN) 2+ lesions in women aged older than 65 years. MATERIALS AND METHODS This is a retrospective cohort study. Multiple logistic regressions were used to compare the efficiency of the HPV test, cytology, and previous screening history for the diagnosis of histologically proven CIN 2+ lesions. RESULTS A total of 5,427 women were included in the study. A total of 2,143 women were tested with HPV and 52 (2.4%) of them were HPV-positive. Abnormal cytology was detected in 359 (6.6%) women. Most of the women (70.4%) had inadequate screening in the previous 10 years. According to regression analysis, an HPV-positive test increases the risk of probability of CIN 2+ 136.111 times [95% CI for odds ratio (OR) = 41.212-449.538] compared with an HPV-negative test ( p < .001). Abnormal cytology increases the probability of CIN 2+ 13.072 times (95% CI for OR = 3.878-44.062) compared with normal cytology ( p < .001). Inadequate or positive previous screening increases the likelihood of CIN 2+ 9.705 times (95% CI for OR = 1.603-58.756) compared with adequate and negative previous screening ( p = .013). CONCLUSIONS Adequate previous screening is a valuable strategy, and abnormal cytology is an important screening test in women aged older than 65 years. However, the HPV test is the most determinant parameter for CIN 2+ risk in elderly women.
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Affiliation(s)
- Serap Firtina Tuncer
- Department of Obstetrics and Gynecology, Antalya Education & Research Hospital, Antalya, Turkey
| | - Hasan Aykut Tuncer
- Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Akdeniz University School of Medicine Hospital, Antalya, Turkey
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Pankakoski M, Sarkeala T, Anttila A, Heinävaara S. Effectiveness of Cervical Testing in and outside a Screening Program-A Case-Control Study. Cancers (Basel) 2022; 14:5193. [PMID: 36358612 PMCID: PMC9653595 DOI: 10.3390/cancers14215193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 04/29/2024] Open
Abstract
In many countries with organized cervical cancer screening, opportunistic Pap and human papillomavirus (HPV) tests are common. However, little is known about their effectiveness. We examined the effect of testing in and outside the Finnish screening program on the risk of cervical cancer. We conducted a case-control study that involved 1677 cases with invasive cervical cancer that were diagnosed between 2010 and 2019. Five- and three-year test intervals were analyzed across all ages, by age group and by cancer morphology subtype. Conditional logistic regression was used, adjusting for socioeconomic variables. Women undergoing any kind of cervical test had a significantly lowered risk of cervical cancer (adjusted OR = 0.43, 95% CI = 0.38-0.48, tests in five-year intervals). The results were similar, regardless of whether the test had been taken in the screening program or outside of it, or whether the interval was five years or three years. Testing of women at ages 35-64 showed the strongest effects, but moderate preventive effects were seen until age 79. No significant effect was seen below age 30. Tests in and outside the program were effective at the screening target age. However, participation in the program should be encouraged for optimal cost-effectiveness. Preventive effects were also seen above the program target ages.
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Affiliation(s)
- Maiju Pankakoski
- Finnish Cancer Registry, Unioninkatu 22, 00130 Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Haartmaninkatu 8, 00014 Helsinki, Finland
| | - Tytti Sarkeala
- Finnish Cancer Registry, Unioninkatu 22, 00130 Helsinki, Finland
| | - Ahti Anttila
- Finnish Cancer Registry, Unioninkatu 22, 00130 Helsinki, Finland
| | - Sirpa Heinävaara
- Finnish Cancer Registry, Unioninkatu 22, 00130 Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Haartmaninkatu 8, 00014 Helsinki, Finland
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Understanding cervical cancer after the age of routine screening: Characteristics of cases, treatment, and survival in the United States. Gynecol Oncol 2022; 165:67-74. [PMID: 35115179 PMCID: PMC8969176 DOI: 10.1016/j.ygyno.2022.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Given that cervical cancer incidence rates do not decline in women >65, there is generally limited screening, and these women have a poor prognosis, it is imperative to better understand this population. We aim to describe the characteristics, treatment, and survival of women >65 diagnosed with cervical cancer. METHODS SEER-Medicare 2004-2013 data was used to describe 2274 patients >65 diagnosed with cervical cancer. Five-year cancer-specific survival was estimated using the Kaplan-Meier method. Multivariable Poisson and Cox regression analyses identified characteristics associated with treatment and mortality. RESULTS The median age was 76.1 years, with nearly one-third of cases occurring in women >80 years. Most patients were non-Hispanic White (64.8%), had comorbidity scores ≥ 1 (53.9%) and squamous histology (66.3%). Most women were diagnosed at stage II or higher (62.7%), including nearly one-quarter at Stage IV (23.1%). Nearly 15% of patients were not treated (14.6%). Lack of treatment was associated with oldest age (>80), comorbidity scores ≥3, and stage IV disease. Five-year cancer-specific survival was 50%. Increasing age and stage at diagnosis were significantly associated with lower cancer-specific survival whereas treatment was strongly associated with increased survival. CONCLUSION Most women >65 with cervical cancer are diagnosed with locally advanced or metastatic disease and many do not receive treatment. Survival is improved with early-stage diagnosis and treatment. These findings, coupled with the fact that women >65 constitute an increasing proportion of the population, highlight the need to re-evaluate screening and treatment practices in this population to detect cervical cancer at earlier stages and increase survival. NOVELTY AND IMPACT STATEMENT In SEER-Medicare linked data from 2004 to 2013, most women >65 with cervical cancer were diagnosed with locally advanced or metastatic disease. Both receipt of treatment and survival decreased with increasing age. These findings, coupled with the fact that women aged >65 constitute an increasing proportion of the population, highlight the need to re-evaluate screening and treatment practices in older women to detect cervical cancer at earlier stages and increase survival.
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Castanon A, Kamineni A, Elfström KM, Lim AWW, Sasieni P. Exposure Definition in Case-Control Studies of Cervical Cancer Screening: A Systematic Literature Review. Cancer Epidemiol Biomarkers Prev 2021; 30:2154-2166. [PMID: 34526301 PMCID: PMC8643309 DOI: 10.1158/1055-9965.epi-21-0376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/14/2021] [Accepted: 09/08/2021] [Indexed: 01/07/2023] Open
Abstract
The first step in evaluating the effectiveness of cervical screening is defining exposure to screening. Our aim was to describe the spectrum of screening exposure definitions used in studies of the effectiveness of cervical screening. This systematic review included case-control studies in a population-based screening setting. Outcome was incidence of cervical cancer. Three electronic databases were searched from January 1, 2012 to December 6, 2018. Articles prior to 2012 were identified from a previous review. The qualitative synthesis focused on describing screening exposure definitions reported in the literature and the methodologic differences that could have an impact on the association between screening and cervical cancer. Forty-one case-control studies were included. Six screening exposure definitions were identified. Cervical cancer risk on average decreased by 66% when screening exposure was defined as ever tested, by 77% by time since last negative test, and by 79% after two or more previous tests. Methodologic differences included composition of the reference group and whether diagnostic and/or symptomatic tests were excluded from the analysis. Consensus guidelines to standardize exposure definitions are needed to ensure evaluations of cervical cancer screening can accurately measure the impact of transitioning from cytology to human papillomavirus-based screening and to allow comparisons between programs.
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Affiliation(s)
- Alejandra Castanon
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Cancer Prevention Group, Innovation Hub, Guys Cancer Centre, Guys Hospital, Great Maze Pond, London, United Kingdom.
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - K Miriam Elfström
- Institutionen för Laboratoriemedicin, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anita W W Lim
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Cancer Prevention Group, Innovation Hub, Guys Cancer Centre, Guys Hospital, Great Maze Pond, London, United Kingdom
| | - Peter Sasieni
- King's College London, Faculty of Life Sciences & Medicine, School of Cancer & Pharmaceutical Sciences, Cancer Prevention Group, Innovation Hub, Guys Cancer Centre, Guys Hospital, Great Maze Pond, London, United Kingdom
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Altová A, Kulhánová I, Brůha L, Lustigová M. Breast and cervical cancer screening attendance among Czech women. Cent Eur J Public Health 2021; 29:90-95. [PMID: 34245547 DOI: 10.21101/cejph.a6623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of the study was to investigate the variation in breast and cervical cancer screening attendance among Czech women by age and in regions in 2009-2017. METHODS The data from the health insurance company that covers around 50% of the Czech population were used to calculate age-specific attendance rates and standardized attendance rates by year and region. RESULTS In 2017, the attendance of all eligible women was 52% in breast cancer screening and 46% in cervical cancer screening. There were differences in attendance among groups of women. Women aged 45-49 had attendance rates in both screenings around 60%, while 39% of women aged 75-79 attended breast cancer screening, and 23% attended cervical cancer screening. In regions, attendance ranged from 38% to 70% in breast cancer screening and from 32% to 55% in cervical cancer screening. CONCLUSIONS We identified the age-specific differences and regional variation in both breast and cervical cancer screening attendance among Czech women. Those with lower attendance may have a higher risk of dying from breast and cervical cancers. Mitigating this risk should be a priority of public health policies.
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Affiliation(s)
- Anna Altová
- Department of Demography and Geodemography, Faculty of Science, Charles University, Prague, Czech Republic
| | - Ivana Kulhánová
- Department of Demography and Geodemography, Faculty of Science, Charles University, Prague, Czech Republic.,Department of Social Geography and Regional Development, Faculty of Science, Charles University, Prague, Czech Republic
| | - Lukáš Brůha
- Department of Applied Geoinformatics and Cartography, Faculty of Science, Charles University, Prague, Czech Republic
| | - Michala Lustigová
- Department of Social Geography and Regional Development, Faculty of Science, Charles University, Prague, Czech Republic.,National Institute of Public Health, Prague, Czech Republic
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Koc S, Yuksel D, Kayikcioglu F. Colposcopic histopathology results of patients over 50: Is HPV genotyping useful? Curr Probl Cancer 2021; 46:100764. [PMID: 34275530 DOI: 10.1016/j.currproblcancer.2021.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND To determine the rate of high-grade cervical intraepithelial lesion and cancer (HSIL+) diagnosis as a result of colposcopic histopathology in patients aged ≥50 years and to investigate the role of cytology, Human Papillomavirus (HPV) test positivity and HPV genotyping in predicting HSIL+. MATERIAL AND METHOD The study included 1102 patients aged ≥50 as study group and 2723 patients aged <50 as control group who were admitted to our colposcopy unit between January 1, 2015 and December 31, 2019 and underwent colposcopy for the first time. The patients with HSIL+ were compared as Cytology group and HPV group in the study group. To evaluate the impact of genotyping HPV positive group was compared in terms of HSIL+ results in subgroups with HPV16/18 and HPV other types positivity. Patients diagnosed with cancer in the same period were compared in terms of age, stage and histology as screening cancer group and symptomatic cancer groups. RESULTS The rate of cervical cancer in the study group was 2.2% and 1.2 % in the control group. In patients diagnosed with cancer, Federation of Gynecology and Obstetrics stage was ≥ stage IB2 in 57.4% of cases in the symptomatic cancer group and in 18.9% of cases in the screening cancer group. The HPV 16/18 positivity rate in HSIL+ patients were 75.0% and 79.5% in the study and control group, respectively. CONCLUSION Cervical cancer rates were found to be high in the group aged ≥ 50 years. HPV genotyping is as effective in patients ≥50 years of age as in those aged < 50 years. Patients diagnosed as a result of screening are caught in the early stages and therefore with increased general life expectancy, the age at which screening is discontinued should be re-evaluated.
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Affiliation(s)
- Sevgi Koc
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey.
| | - Dilek Yuksel
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey
| | - Fulya Kayikcioglu
- Department of Gynecologic Oncology, University of Health Sciences Turkey, Etlik Zubeyde Hanim Women's Health Education and Research Hospital, Ankara, Turkey
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Keltto N, Leivonen A, Pankakoski M, Sarkeala T, Heinävaara S, Anttila A. Cervical testing beyond the screening target age - A register-based cohort study from Finland. Gynecol Oncol 2021; 162:315-321. [PMID: 34074539 DOI: 10.1016/j.ygyno.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Natalie Keltto
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland.
| | - Aku Leivonen
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland
| | - Maiju Pankakoski
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland
| | - Tytti Sarkeala
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland
| | - Sirpa Heinävaara
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland
| | - Ahti Anttila
- Mass Screening Registry, Finnish Cancer Registry, Helsinki, Finland
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Tranberg M, Petersen LK, Elfström KM, Hammer A, Blaakær J, Bennetsen MH, Jensen JS, Andersen B. Expanding the upper age limit for cervical cancer screening: a protocol for a nationwide non-randomised intervention study. BMJ Open 2020; 10:e039636. [PMID: 33154056 PMCID: PMC7646343 DOI: 10.1136/bmjopen-2020-039636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Cervical cancer screening ceases between the ages of 60 and 65 in most countries. Yet, a relatively high proportion of cervical cancers are diagnosed in women above the screening age. This study will evaluate if screening of women aged 65-69 years may result in increased detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with women not invited to screening. Invited women may choose between general practitioner (GP)-based screening or cervico-vaginal self-sampling. Furthermore, the study will assess if self-sampling is superior to GP-based screening in reaching long-term unscreened women. METHODS AND ANALYSIS This population-based non-randomised intervention study will include 10 000 women aged 65-69 years, with no record of a cervical cytology sample or screening invitation in the 5 years before inclusion. Women who have opted-out of the screening programme or have a record of hysterectomy or cervical amputation are excluded. Women residing in the Central Denmark Region (CDR) are allocated to the intervention group, while women residing in the remaining four Danish regions are allocated to the reference group. The intervention group is invited for human papillomavirus-based screening by attending routine screening at the GP or by requesting a self-sampling kit. The reference group receives standard care which is the opportunity to have a cervical cytology sample obtained at the GP or by a gynaecologist. The study started in April 2019 and will run over the next 4.5 years. The primary outcome will be the proportion of CIN2+ detected in the intervention and reference groups. In the intervention group, the proportion of long-term unscreened women attending GP-based screening or self-sampling will be compared. ETHICS AND DISSEMINATION The study has been submitted to the Ethical Committee in the CDR which deemed that the study was not notifiable to the Committee and informed consent is therefore not required. The study is approved by the Danish Data Protection Regulation and the Danish Patient Safety Authority. Results will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04114968.
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Affiliation(s)
- Mette Tranberg
- Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Lone Kjeld Petersen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
| | - Klara Miriam Elfström
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Center of Stockholm-Gotland, Stockholm, Sweden
| | - Anne Hammer
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Regionshospitalet Herning, Herning, Denmark
| | - Jan Blaakær
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
- OPEN, Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Jørgen Skov Jensen
- Research Unit for Reproductive Microbiology, Statens Serum Institut, Copenhagen, Denmark
| | - Berit Andersen
- Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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12
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Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A, Guerra CE, Oeffinger KC, Shih YCT, Walter LC, Kim JJ, Andrews KS, DeSantis CE, Fedewa SA, Manassaram-Baptiste D, Saslow D, Wender RC, Smith RA. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin 2020; 70:321-346. [PMID: 32729638 DOI: 10.3322/caac.21628] [Citation(s) in RCA: 426] [Impact Index Per Article: 106.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022] Open
Abstract
The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.
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Affiliation(s)
| | - Andrew M D Wolf
- Division of General Medicine, Geriatrics, and Palliative Care, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Timothy R Church
- Division of Environmental Health Sciences, University of Minnesota School of Public Health and Masonic Cancer Center, Minneapolis, Minneapolis
| | - Ruth Etzioni
- Public Health Sciences Division, the Fred Hutchinson Cancer Research Center, Seattle, Washington
- Biostatistics, University of Washington Seattle, Seattle, Washington
| | - Christopher R Flowers
- Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Abbe Herzig
- University of Albany School of Public Health, Albany, New York
| | - Carmen E Guerra
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Kevin C Oeffinger
- Duke Cancer Institute Center for Onco-Primary Care, Durham, North Carolina
| | - Ya-Chen Tina Shih
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Louise C Walter
- Division of Geriatrics, University of California-San Francisco, San Francisco, California
- Division of Geriatrics, San Francisco VA Health Care System, San Francisco, California
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kimberly S Andrews
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
| | - Carol E DeSantis
- Surveillance Research, American Cancer Society, Atlanta, Georgia
| | - Stacey A Fedewa
- Surveillance Research, American Cancer Society, Atlanta, Georgia
| | | | - Debbie Saslow
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
| | - Richard C Wender
- Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert A Smith
- Prevention and Early Detection Department, American Cancer Society, Atlanta, Georgia
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13
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Landy R, Sasieni PD, Mathews C, Wiggins CL, Robertson M, McDonald YJ, Goldberg DW, Scarinci IC, Cuzick J, Wheeler CM. Impact of screening on cervical cancer incidence: A population-based case-control study in the United States. Int J Cancer 2020; 147:887-896. [PMID: 31837006 PMCID: PMC7282928 DOI: 10.1002/ijc.32826] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/03/2022]
Abstract
Cervical cancer is widely preventable through screening, but little is known about the duration of protection offered by a negative screen in North America. A case-control study was conducted with records from population-based registries in New Mexico. Cases were women diagnosed with cervical cancer in 2006-2016, obtained from the Tumor Registry. Five controls per case from the New Mexico HPV Pap Registry were matched to cases by sex, age and place of residence. Dates and results of all cervical screening and diagnostic tests since 2006 were identified from the pap registry. We estimated the odds ratio of nonlocalized (Stage II+) and localized (Stage I) cervical cancer associated with attending screening in the 3 years prior to case-diagnosis compared to women not screened in 5 years. Of 876 cases, 527 were aged 25-64 years with ≥3 years of potential screening data. Only 38% of cases and 61% of controls attended screening in a 3-year period. Women screened in the 3 years prior to diagnosis had 83% lower risk of nonlocalized cancer (odds ratio [OR] = 0.17, 95% CI: 0.12-0.24) and 48% lower odds of localized cancer (OR = 0.52, 95% CI: 0.38-0.72), compared to women not screened in the 5 years prior to diagnosis. Women remained at low risk of nonlocalized cancer for 3.5-5 years after a negative screen compared to women with no negative screens in the 5 years prior to diagnosis. Routine cervical screening is effective at preventing localized and nonlocalized cervical cancers; 3 yearly screening prevents 83% of nonlocalized cancers, with no additional benefit of more frequent screening. Increasing screening coverage remains essential to further reduce cervical cancer incidence.
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Affiliation(s)
- Rebecca Landy
- Wolfson Institute of Preventive MedicineQueen Mary University of LondonLondonUnited Kingdom
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human ServicesBethesdaMD
| | - Peter D. Sasieni
- School of Cancer & Pharmaceutical SciencesKing's College LondonLondonUnited Kingdom
| | - Christopher Mathews
- School of Cancer & Pharmaceutical SciencesKing's College LondonLondonUnited Kingdom
| | - Charles L. Wiggins
- Department of Internal MedicineUniversity of New Mexico Comprehensive Cancer Center and University of New Mexico Health Sciences CenterAlbuquerqueNM
| | - Michael Robertson
- The Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer Center, University of New Mexico Health Sciences CenterAlbuquerqueNM
| | - Yolanda J. McDonald
- Department of Human and Organizational DevelopmentVanderbilt UniversityNashvilleTN
| | | | - Isabel C. Scarinci
- Division of Preventive MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Jack Cuzick
- Wolfson Institute of Preventive MedicineQueen Mary University of LondonLondonUnited Kingdom
| | - Cosette M. Wheeler
- Department of Pathology and Obstetrics & GynecologyUniversity of New Mexico Health Sciences CenterAlbuquerqueNM
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14
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Cejtin HE, Schmidt JB. Prevalence of Inadequate Cervical Cancer Screening in Low-Income Older Women. J Womens Health (Larchmt) 2020; 29:1350-1353. [PMID: 32155360 DOI: 10.1089/jwh.2019.8017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: At age 65 years, cervical cancer screening is not recommended in women with an adequate history of negative screening tests in the previous 10 years if they do not have other high-risk factors for cervical cancer. The purpose of this study was to assess the proportion of older low-income women at a safety net urban hospital system without other risk factors for cervical cancer who should have cervical cancer screening because of an inadequate screening history, and to evaluate if they were triaged appropriately. Materials and Methods: Medical records from 200 women 65 years and older at the Gynecology clinic of John H. Stroger Hospital of Cook County were evaluated for adequate cervical cancer screening or hysterectomy to see if they could stop screening. Charts were reviewed to see if a screen was performed, and the results of that test and associated biopsies. Data using cytology alone and the cytology/human papillomavirus cotest were compared. Chi-square test was used. Results: Of 200 women included, the median age was 68.5 years, range 65-93 years. Of these women, 81 (40.5%) did not need testing because of adequate screening or hysterectomy for benign indications. There were 119 (59.5%) women who needed to continue testing because of inadequate screening. Of these women, 46 (38.7%) did not have appropriate testing carried out. Of 73 correctly screened women, 16 (21.9%) required biopsies, of which 11 demonstrated high-grade lesions or cancers. Conclusions: Many older women, especially low-income women, need to continue screening for cervical cancer because of inadequate screening histories. This is a group at increased risk for cervical cancer, and it is imperative that clinicians evaluate previous test results before exiting a woman from screening at age 65 years.
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Affiliation(s)
- Helen E Cejtin
- John H. Stroger, Jr. Hospital of Cook County, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Julie B Schmidt
- Jesse Brown VA Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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15
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Elit L. Cervical screening in women over 65. PRO: Are we asking the right question? Gynecol Oncol 2019; 142:381-2. [PMID: 27545585 DOI: 10.1016/j.ygyno.2016.08.230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/21/2014] [Accepted: 04/07/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Laurie Elit
- Juravinski Cancer Centre, 699 Concession Street, Hamilton, Canada L8V 5C2.
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16
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Hammer A, Soegaard V, Maimburg RD, Blaakaer J. Cervical cancer screening history prior to a diagnosis of cervical cancer in Danish women aged 60 years and older-A national cohort study. Cancer Med 2019; 8:418-427. [PMID: 30600650 PMCID: PMC6346234 DOI: 10.1002/cam4.1926] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/19/2018] [Accepted: 11/23/2018] [Indexed: 01/28/2023] Open
Abstract
The incidence and mortality of cervical cancer are high in Danish women aged 60 years and older who are about to exit the cervical cancer screening program. The present study aimed to describe the screening history in women ≥60 years old, diagnosed with cervical cancer in Denmark, 2009‐2013. We retrieved information on cases of cervical cancer and previous cervical cancer screening from national registries. During the study period, a total of 1907 women were diagnosed with cervical cancer, 574 (30.1%) of which were ≥60 years old. The majority of women were diagnosed with squamous cell carcinoma (73.7%) and advanced‐stage disease (ASD, ie, ≥FIGO IIB; 63.1%). The proportion of ASD increased with age, from 51.9% in women aged 60‐64% to 76.7% in women aged 75‐79. Among screened women (n = 377), 22.8% had a cervical cytology within 5 years of diagnosis, 73.3% of which were normal, and 45.1% were diagnosed with ASD. Women who had been sufficiently screened prior to screening exit (≥2 normal cytology test in the age interval 50‐59) accounted for 18.1%. Of note, 53.8% of the sufficiently screened women were diagnosed with ASD. Sufficiently screened women were less likely to be diagnosed with ASD compared to never‐screened women (53.8% vs 67.5%, P < 0.020), but no difference was observed between sufficiently and insufficiently screened women (53.8% vs 63.4%, P = 0.091). Our findings suggest that cancer in older women may occur due to insufficient screening prior to screening exit, a low sensitivity of screening, and premature screening exit.
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Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Vibeke Soegaard
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Randers Regional Hospital, Randers, Denmark
| | - Rikke D Maimburg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jan Blaakaer
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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17
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Navigating the cervical cancer screening guidelines for women aged older than 65 years. Menopause 2017; 24:1302-1303. [DOI: 10.1097/gme.0000000000000913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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Wang J, Andrae B, Sundström K, Ploner A, Ström P, Elfström KM, Dillner J, Sparén P. Effectiveness of cervical screening after age 60 years according to screening history: Nationwide cohort study in Sweden. PLoS Med 2017; 14:e1002414. [PMID: 29065127 PMCID: PMC5655486 DOI: 10.1371/journal.pmed.1002414] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/25/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The relatively high incidence of cervical cancer in women at older ages is a continuing concern in countries with long-established cervical screening. Controversy remains on when and how to cease screening. Existing population-based studies on the effectiveness of cervical screening at older ages have not considered women's screening history. We performed a nationwide cohort study to investigate the incidence of cervical cancer after age 60 years and its association with cervical screening at age 61-65, stratified by screening history at age 51-60. METHODS AND FINDINGS Using the Total Population Register, we identified 569,132 women born between 1 January 1919 and 31 December 1945, resident in Sweden since age 51. Women's cytological screening records, cervical cancer occurrence, and FIGO stage (for those diagnosed with cancer) were retrieved from national registers and medical charts. We calculated the cumulative incidence of cervical cancer from age 61 to age 80 using a survival function considering competing risk, and estimated the hazard ratio (HR) of cervical cancer in relation to screening status at age 61-65 from Cox models, adjusted for birth cohort and level of education, conditioning on women's screening history in their 50s. In women unscreened in their 50s, the cumulative incidence up to age 80 was 5.0 per 1,000 women, and screening at age 61-65 was associated with a lower risk for cervical cancer (HR = 0.42, 95% CI 0.24-0.72), corresponding to a decrease of 3.3 cancer cases per 1,000 women. A higher cumulative incidence and similarly statistically significant risk decrease was seen for women with abnormal smears in their 50s. In women adequately or inadequately screened with only normal results between age 51 and age 60, the cumulative incidence of cervical cancer from age 61 to 80 was 1.6 and 2.5 per 1,000 women, respectively, and further screening at age 61-65 was not associated with statistically significant decreases of cervical cancer risk up to age 80, but with fewer cancer cases of advanced stages at age 61-65. Adjustment for potential lifestyle confounders was limited. CONCLUSIONS In this study, cervical screening with cytology at age 61-65 was associated with a statistically significant reduction of subsequent cervical cancer risk for women who were unscreened, or screened with abnormalities, in their 50s. In women screened with normal results in their 50s, the risk for future cancer was not sizeable, and the risk reduction associated with continued screening appeared limited. These findings should inform the current debate regarding age and criteria to discontinue cervical screening.
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Affiliation(s)
- Jiangrong Wang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Bengt Andrae
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Centre for Research and Development, Uppsala University/Region of Gävleborg, Gävle, Sweden
| | - Karin Sundström
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Ploner
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Peter Ström
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - K. Miriam Elfström
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Dillner
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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19
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White MC, Shoemaker ML, Benard VB. Cervical Cancer Screening and Incidence by Age: Unmet Needs Near and After the Stopping Age for Screening. Am J Prev Med 2017; 53:392-395. [PMID: 28473240 PMCID: PMC5821231 DOI: 10.1016/j.amepre.2017.02.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/01/2017] [Accepted: 02/24/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Leading professional organizations recommend cervical cancer screening for average-risk women aged 21-65 years. For average-risk women aged >65 years, routine screening may be discontinued if "adequate" screening with negative results is documented. Screening is recommended after age 65 years for women who do not meet adequate prior screening criteria or are at special risk. METHODS Authors examined the most recent cervical cancer incidence data from two federal cancer surveillance programs for all women by age and race, corrected for hysterectomy status. The 2013 and 2015 National Health Interview Surveys were analyzed in 2016 to examine the proportion of women aged 41-70 years without a hysterectomy who reported that they never had a Pap test or that their most recent Pap test was >5 years ago (not recently screened). RESULTS The incidence rate for cervical cancer among older women, corrected for hysterectomy status, did not decline until age ≥85 years. The proportion not recently screened increased with age, from 12.1% for women aged 41-45 years to 18.4% for women aged 61-65 years. CONCLUSIONS Even among women within the recommended age range for routine screening, many are not up to date, and a substantial number of women approach the "stopping" age for cervical cancer screening without an adequate prior screening history. Efforts are needed to reach women who have not been adequately screened, including women aged >65 years, to prevent invasive cervical cancer cases and deaths among older women.
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Affiliation(s)
- Mary C White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
| | - Meredith L Shoemaker
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Vicki B Benard
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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20
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Castillo M, Astudillo A, Clavero O, Velasco J, Ibáñez R, de Sanjosé S. [Evaluation of mortality after the analysis of the screening history in women diagnosed with infiltrating cervical cancer]. Aten Primaria 2017. [PMID: 28629884 PMCID: PMC6836921 DOI: 10.1016/j.aprim.2017.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objetivo Evaluar el impacto de la ausencia de cribado en la incidencia de cáncer de cuello uterino durante el periodo 2000-2010 en el Principado de Asturias. Diseño Estudio retrospectivo. Emplazamiento Todos los hospitales públicos de Asturias. Mediciones principales Fueron revisadas 374 historias clínicas de mujeres diagnosticadas de cáncer de cuello uterino. La información clínica, el estadio FIGO y los datos de las citologías previas fueron obtenidos de las historias clínicas e informes de anatomía patológica. Se realizó análisis bivariante utilizando el test de chi-cuadrado de Pearson y regresión logística para el cálculo de odds ratio e intervalos de confianza al 95%. Resultados El 65,6% de las mujeres diagnosticadas de cáncer de cérvix entre los 25 y los 70 años no habían realizado una citología en al menos los 5 años y medio anteriores al diagnóstico. Este porcentaje se relacionó con la mayor edad al diagnóstico, la presencia de síntomas asociados y con un estadio tumoral avanzado en el momento del diagnóstico. En las mujeres diagnosticadas con una edad mayor de 70 años se objetivó que el 83,3% no habían realizado ninguna citología con anterioridad al momento del diagnóstico. Conclusión La implantación de un buen programa de cribado de cáncer cervicouterino y una calidad óptima del sistema en cada uno de los procedimientos que lo integran contribuiría a disminuir la incidencia y la mortalidad por cáncer de cuello uterino en Asturias.
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Affiliation(s)
- Marta Castillo
- Servicio de Ginecología y Obstetricia, Hospital de Jarrio, SESPA, Coaña, Asturias, España.
| | - Aurora Astudillo
- Servicio de Anatomía Patológica, Hospital Universitario Central de Asturias, SESPA, Oviedo, Asturias, España
| | - Omar Clavero
- Infections and Cancer Unit, Cancer Epidemiology Research Programme, Institut Català d'Oncologia-IDIBELL, l'Hospitalet de Llobregat, Barcelona, España
| | - Julio Velasco
- Servicio de Anatomía Patológica, Centro Médico de Asturias, Oviedo, Asturias, España
| | - Raquel Ibáñez
- Infections and Cancer Unit, Cancer Epidemiology Research Programme, Institut Català d'Oncologia-IDIBELL, l'Hospitalet de Llobregat, Barcelona, España
| | - Silvia de Sanjosé
- Infections and Cancer Unit, Cancer Epidemiology Research Programme, Institut Català d'Oncologia-IDIBELL, l'Hospitalet de Llobregat, Barcelona, España; CIBER Epidemiology and Public Health (CIBERESP), España
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21
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Hammer A, Kahlert J, Rositch A, Pedersen L, Gravitt P, Blaakaer J, Soegaard M. The temporal and age-dependent patterns of hysterectomy-corrected cervical cancer incidence rates in Denmark: a population-based cohort study. Acta Obstet Gynecol Scand 2016; 96:150-157. [DOI: 10.1111/aogs.13057] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Anne Hammer
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - Johnny Kahlert
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Anne Rositch
- Department of Epidemiology; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
| | - Lars Pedersen
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
| | - Patti Gravitt
- Department of Global Health; George Washington University; Washington DC USA
| | - Jan Blaakaer
- Department of Obstetrics and Gynecology; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - Mette Soegaard
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
- Department of Clinical Epidemiology; Aarhus University Hospital; Aarhus Denmark
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22
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Case-control study of cervical cancer and gynecologic screening: A SEER-Medicare analysis. Gynecol Oncol 2016; 142:395-400. [DOI: 10.1016/j.ygyno.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/21/2016] [Accepted: 06/26/2016] [Indexed: 11/19/2022]
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23
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Bowles EJA, Gao H, Brandzel S, Bradford SC, Buist DSM. Comparative effectiveness of two outreach strategies for cervical cancer screening. Prev Med 2016; 86:19-27. [PMID: 26820221 PMCID: PMC4902104 DOI: 10.1016/j.ypmed.2016.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/04/2016] [Accepted: 01/18/2016] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Erin J Aiello Bowles
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | - Hongyuan Gao
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Susan Brandzel
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Susan Carol Bradford
- Department of Clinical Improvement and Prevention, Group Health Cooperative, 201 16th Ave E, Seattle, WA 98112, USA
| | - Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
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Myriokefalitaki E, Potdar N, Barnfield L, Davies Q, Moss EL. Cervical cancer still presents symptomatically 20 years after the introduction of a structured national screening programme. Cytopathology 2016; 27:229-36. [PMID: 26919275 DOI: 10.1111/cyt.12315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate the pattern of presentation of cervical cancer and to identify the characteristics of women who present symptomatically with cervical cancer. METHODS A retrospective study of all cervical cancer cases diagnosed over a 4-year period. Details of mode of presentation, stage at diagnosis and cytological/gynaecological history were collated. RESULTS In total, 148 cases were identified with a median age of 46 years (range, 20-91 years). In this population, 112 (75.7%) women were within the screening age range. Forty-eight (33.6%) were asymptomatic at diagnosis and presented through the colposcopy clinic. All asymptomatic women (100%) had stage I disease at diagnosis, compared with 37.2% of the symptomatic group (P < 0.001). Postmenopausal bleeding was the most common presenting symptom (33%), followed by postcoital bleeding (14.2%), intermenstrual bleeding (12.2%) and increased vaginal discharge (3.4%). The majority of symptomatic women presented through colposcopy, gynaecological oncology or gynaecology clinics (87.6%); however, 6.5% presented through the emergency department. Women who presented symptomatically were significantly older than asymptomatic women (54.9 versus 38.1 years, P < 0.001). Women at risk of social isolation (non-English speakers, alcohol abusers, heavy smokers, receiving treatment for psychiatric disease) were more likely to present with symptoms, through the emergency department and with advanced disease at diagnosis (stage II+) (P < 0.001). CONCLUSIONS A review of local cervical cancer cases can highlight areas of weakness in a screening programme and can identify populations who are at risk in presenting symptomatically with advanced disease.
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Affiliation(s)
| | - N Potdar
- University Hospitals of Leicester, Leicester, UK
| | - L Barnfield
- University Hospitals of Leicester, Leicester, UK
| | - Q Davies
- University Hospitals of Leicester, Leicester, UK
| | - E L Moss
- University Hospitals of Leicester, Leicester, UK
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Evidence of disrupted high-risk human papillomavirus DNA in morphologically normal cervices of older women. Sci Rep 2016; 6:20847. [PMID: 26875676 PMCID: PMC4753489 DOI: 10.1038/srep20847] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 01/12/2016] [Indexed: 12/31/2022] Open
Abstract
High-risk human papillomavirus (HR-HPV) causes nearly 100% of cervical carcinoma. However, it remains unclear whether HPV can establish a latent infection, one which may be responsible for the second peak in incidence of cervical carcinoma seen in older women. Therefore, using Ventana in situ hybridisation (ISH), quantitative PCR assays and biomarkers of productive and transforming viral infection, we set out to provide the first robust estimate of the prevalence and characteristics of HPV genomes in FFPE tissue from the cervices of 99 women undergoing hysterectomy for reasons unrelated to epithelial abnormality. Our ISH assay detected HR-HPV in 42% of our study population. The majority of ISH positive samples also tested HPV16 positive using sensitive PCR based assays and were more likely to have a history of preceding cytological abnormality. Analysis of subsets of this population revealed HR-HPV to be transcriptionally inactive as there was no evidence of a productive or transforming infection. Critically, the E2 gene was always disrupted in those HPV16 positive cases which were assessed. These findings point to a reservoir of transcriptionally silent, disrupted HPV16 DNA in morphologically normal cervices, re-expression of which could explain the increase in incidence of cervical cancer observed in later life.
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Luquain A, Belglaiaa E, Guenat D, Vrecko S, Riethmuller D, Valmary-Degano S, Bedgedjian I, Chouham S, Prétet JL, Mougin C. High prevalence of abnormal cervical smears in a hospital cohort of French women beyond the upper age limit screening program. Prev Med 2015; 81:157-62. [PMID: 26348451 DOI: 10.1016/j.ypmed.2015.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/27/2015] [Accepted: 08/31/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the prevalence of cytological abnormalities and high risk Human PapillomaVirus (hrHPV) in cervical smears from French women aged over 65 years who attended the referent Gynecology Clinic of the Besançon University Hospital. METHODS Between 2002 and 2012, 796 French women aged 66-99 years were cotested for cytology and hrHPV by Hybrid Capture 2 (hc2). hc2-positive cases were subjected to real time PCR for specific HPV 16/18/45 genotyping. Women with normal Pap smears and positive for hrHPV were followed-up every 12 months. RESULTS Cytological abnormalities were detected in more than 30% of women and cervical cancers (CC) in 2.9% of women. Benign lesions were more frequent in women aged 66-75 years while (pre)-malignant lesions were preferentially found in women over 76. The prevalence of hrHPV was 22.7%. HPV 16 was the most frequent (23.8%), followed by HPV 45 (7.7%) and HPV 18 (3.9%). The rate of hrHPV increased with the lesion severity and HPV 16 was identified in 50% of CC. Among the followed-up women, those who developed CIN3 were HPV16 positive at study entry. CONCLUSION The study provides important estimates of the prevalence of cervical abnormalities and hrHPV positivity in a French hospital based-population over 65. Findings suggest to consider this high risk population in regards to cervical cancer.
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Affiliation(s)
- Alexandra Luquain
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France.
| | - Essaada Belglaiaa
- Laboratoire de Biologie Cellulaire et Génétique Moléculaire, Faculté des Sciences, Université Ibn Zohr, Agadir, Maroc; Université Bourgogne Franche-Comté, F-25000 Besançon, France; EA 3181, LabEx LipSTIC ANR-11-LABX-0021, FED4234, CIC-1431F-25000 Besançon, France.
| | - David Guenat
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France; Université Bourgogne Franche-Comté, F-25000 Besançon, France.
| | - Sindy Vrecko
- Université Bourgogne Franche-Comté, F-25000 Besançon, France.
| | - Didier Riethmuller
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France; Université Bourgogne Franche-Comté, F-25000 Besançon, France; EA 3181, LabEx LipSTIC ANR-11-LABX-0021, FED4234, CIC-1431F-25000 Besançon, France.
| | - Séverine Valmary-Degano
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France; Université Bourgogne Franche-Comté, F-25000 Besançon, France; EA 3181, LabEx LipSTIC ANR-11-LABX-0021, FED4234, CIC-1431F-25000 Besançon, France.
| | | | - Said Chouham
- Laboratoire de Biologie Cellulaire et Génétique Moléculaire, Faculté des Sciences, Université Ibn Zohr, Agadir, Maroc.
| | - Jean-Luc Prétet
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France; Université Bourgogne Franche-Comté, F-25000 Besançon, France; EA 3181, LabEx LipSTIC ANR-11-LABX-0021, FED4234, CIC-1431F-25000 Besançon, France.
| | - Christiane Mougin
- Centre Hospitalier Régional Universitaire de Besançon, F-25000, France; Université Bourgogne Franche-Comté, F-25000 Besançon, France; EA 3181, LabEx LipSTIC ANR-11-LABX-0021, FED4234, CIC-1431F-25000 Besançon, France.
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Hammer A, Rositch AF, Kahlert J, Gravitt PE, Blaakaer J, Søgaard M. Global epidemiology of hysterectomy: possible impact on gynecological cancer rates. Am J Obstet Gynecol 2015; 213:23-29. [PMID: 25724402 DOI: 10.1016/j.ajog.2015.02.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/03/2015] [Accepted: 02/19/2015] [Indexed: 11/26/2022]
Abstract
Despite the fact that hysterectomy is the most common surgical procedure worldwide in gynecology, national reporting of the incidence rate of gynecological cancers rarely removes the proportion no longer at risk of the disease from the population-at-risk-denominator (ie, women who have had a hysterectomy). The incidence rate of gynecological cancers is thus likely underestimated. Because hysterectomy, as well as oophorectomy, incidence varies across countries, age, and over time, meaningful comparison of gynecological cancer incidence rates may be compromised. Without accurate estimates of gynecological cancer incidence rates, performed via removing the proportion of hysterectomized or oophorectomized women from the population-at-risk-denominator, the impact of prevention strategies may be masked or misinterpreted. Furthermore, because national cervical cancer screening guidelines are at least in part based on the national reporting of cervical cancer incidence, it is important that the incidence rate reflects the true population at risk.
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Role of cervical screening in older women. Maturitas 2014; 79:413-20. [DOI: 10.1016/j.maturitas.2014.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 09/23/2014] [Accepted: 09/24/2014] [Indexed: 01/27/2023]
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Rositch AF, Nowak RG, Gravitt PE. Increased age and race-specific incidence of cervical cancer after correction for hysterectomy prevalence in the United States from 2000 to 2009. Cancer 2014; 120:2032-8. [PMID: 24821088 DOI: 10.1002/cncr.28548] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 11/25/2013] [Accepted: 12/02/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Invasive cervical cancer is thought to decline in women over 65 years old, the age at which cessation of routine cervical cancer screening is recommended. However, national cervical cancer incidence rates do not account for the high prevalence of hysterectomy in the United States. METHODS Using estimates of hysterectomy prevalence from the Behavioral Risk Factor Surveillance System (BRFSS), hysterectomy-corrected age-standardized and age-specific incidence rates of cervical cancer were calculated from the Surveillance, Epidemiology, and End Results (SEER) 18 registry in the United States from 2000 to 2009. Trends in corrected cervical cancer incidence across age were analyzed using Joinpoint regression. RESULTS Unlike the relative decline in uncorrected rates, corrected rates continue to increase after age 35-39 (APC(CORRECTED) = 10.43) but at a slower rate than in 20-34 years (APC(CORRECTED) = 161.29). The highest corrected incidence was among 65- to 69-year-old women, with a rate of 27.4 cases per 100,000 women as opposed to the highest uncorrected rate of 15.6 cases per 100,000 aged 40 to 44 years. Correction for hysterectomy had the largest impact on older, black women given their high prevalence of hysterectomy. CONCLUSIONS Correction for hysterectomy resulted in higher age-specific cervical cancer incidence rates, a shift in the peak incidence to older women, and an increase in the disparity in cervical cancer incidence between black and white women. Given the high and nondeclining rate of cervical cancer in women over the age of 60 to 65 years, when women are eligible to exit screening, risk and screening guidelines for cervical cancer in older women may need to be reconsidered.
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Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Rustagi AS, Kamineni A, Weinmann S, Reed SD, Newcomb P, Weiss NS. Cervical screening and cervical cancer death among older women: a population-based, case-control study. Am J Epidemiol 2014; 179:1107-14. [PMID: 24685531 PMCID: PMC3992820 DOI: 10.1093/aje/kwu035] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 02/10/2014] [Indexed: 12/22/2022] Open
Abstract
Recent research suggests that cervical screening of older women is associated with a considerable decrease in cervical cancer incidence. We sought to quantify the efficacy of cervical cytology screening to reduce death from this disease. Among enrollees of 2 US health plans, we compared Papanicolaou smear screening histories of women aged 55-79 years who died of cervical cancer during 1980-2010 (cases) to those of women at risk of cervical cancer (controls). Controls were matched 2:1 to cases on health plan, age, and enrollment duration. Cytology screening during the detectable preclinical phase, estimated as the 5-7 years before diagnosis during which cervical neoplasia is asymptomatic but cytologically detectable, was ascertained from medical records. A total of 39 cases and 80 controls were eligible. The odds ratio of cervical cancer death associated with screening during the presumed detectable preclinical phase was 0.26 (95% confidence interval: 0.10, 0.63) after adjustment for matching characteristics, smoking, marital status, and race/ethnicity using logistic regression. We estimate that cervical cytology screening of all women aged 55-79 years in the United States could avert 630 deaths annually. These results provide a minimum estimate of the efficacy of human papillomavirus DNA screening-a more sensitive test-to reduce cervical cancer death among older women.
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Affiliation(s)
- Alison S. Rustagi
- Correspondence to Dr. Alison S. Rustagi, Department of Global Health, University of Washington, Harris Hydraulics Building, 1510 San Juan Road, Box 357965, Seattle, WA 98195-7765 (e-mail: )
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Abstract
Anne Rositch and colleagues discuss the study by Peter Sasieni and colleagues on cervical cancer screening in older women and describe the further information needed to help inform decisions about whether to extend screening programs beyond 65 years for women with adequate negative screening. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Anne F. Rositch
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Michelle I. Silver
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Patti E. Gravitt
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, United States of America
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Castañón A, Landy R, Cuzick J, Sasieni P. Cervical screening at age 50-64 years and the risk of cervical cancer at age 65 years and older: population-based case control study. PLoS Med 2014; 11:e1001585. [PMID: 24453946 PMCID: PMC3891624 DOI: 10.1371/journal.pmed.1001585] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 11/26/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is little consensus, and minimal evidence, regarding the age at which to stop cervical screening. We studied the association between screening at age 50-64 y and cervical cancer at age 65-83 y. METHODS AND FINDINGS Cases were women (n = 1,341) diagnosed with cervical cancer at age 65-83 y between 1 April 2007 and 31 March 2012 in England and Wales; age-matched controls (n = 2,646) were randomly selected from population registers. Screening details from 1988 onwards were extracted from national databases. We calculated the odds ratios (OR) for different screening histories and subsequent cervical cancer. Women with adequate negative screening at age 65 y (288 cases, 1,395 controls) were at lowest risk of cervical cancer (20-y risk: 8 cancers per 10,000 women) compared with those (532 cases, 429 controls) not screened at age 50-64 y (20-y risk: 49 cancers per 10,000 women, with OR = 0.16, 95% CI 0.13-0.19). ORs depended on the age mix of women because of the weakening association with time since last screen: OR = 0.11, 95% CI 0.08-0.14 at 2.5 to 7.5 y since last screen; OR = 0.27, 95% CI 0.20-0.36 at 12.5 to 17.5 y since last screen. Screening at least every 5.5 y between the ages 50 and 64 y was associated with a 75% lower risk of cervical cancer between the ages 65 and 79 y (OR = 0.25, 95% CI 0.21-0.30), and the attributable risk was such that in the absence of screening, cervical cancer rates in women aged 65+ would have been 2.4 (95% CI 2.1-2.7) times higher. In women aged 80-83 y the association was weaker (OR = 0.49, 95% CI 0.28-0.83) than in those aged 65-69 y (OR = 0.12, 95% CI 0.09-0.17). This study was limited by an absence of data on confounding factors; additionally, findings based on cytology may not generalise to human papillomavirus testing. CONCLUSIONS Women with adequate negative screening at age 50-64 y had one-sixth of the risk of cervical cancer at age 65-83 y compared with women who were not screened. Stopping screening between ages 60 and 69 y in women with adequate negative screening seems sensible, but further screening may be justifiable as life expectancy increases.
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Affiliation(s)
- Alejandra Castañón
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Rebecca Landy
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Peter Sasieni
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Azrad M, Demark-Wahnefried W. The association between adiposity and breast cancer recurrence and survival: A review of the recent literature. Curr Nutr Rep 2013; 3:9-15. [PMID: 24533234 DOI: 10.1007/s13668-013-0068-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Breast Cancer (BC) is the most common and second deadliest malignancy among American women. Many factors contribute to BC prognosis but a key modifiable lifestyle factor is body weight. In this review, we update the reader on the association between adiposity and poor BC outcomes. We summarize the findings from studies that show obesity to be a risk factor for BC recurrence and reduced survival, including research that shows that treatment with aromatase inhibitors in hormone-receptor positive BC survivors who are obese may not be as effective as in normal weight women. In addition, we summarize the findings from studies that show that obesity-induced changes in glucose metabolism, type-2 diabetes and metabolic syndrome contribute to negative outcomes in BC survivors. Given the evidence, there is a critical need to determine whether weight loss can improve outcomes in BC survivors.
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Affiliation(s)
- Maria Azrad
- Department of Nutrition Sciences, University of Alabama at Birmingham (UAB), 1824 6th Avenue, 310B Wallace Tumor Institute, Birmingham, AL 35294
| | - Wendy Demark-Wahnefried
- Department of Nutrition Sciences, University of Alabama at Birmingham (UAB), 1824 6th Avenue, 310B Wallace Tumor Institute, Birmingham, AL 35294 ; UAB Comprehensive Cancer Center, University of Alabama at Birmingham, 1824 6th Avenue, 310D Wallace Tumor Institute, Birmingham, AL 35294
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