Cervical cancer screening policies and coverage in Europe

Cervical cancer screening in Brazilian Amazon Indigenous women: Towards the intensification of public policies for prevention

BACKGROUND

Indigenous women are vulnerable to cervical cancer. Screening is a strategy to reduce the burden of the disease.

OBJECTIVE

To evaluate the prevalence profile of cervical cancer screening cytological results in Brazilian indigenous women by age and frequency of tests compared to non-indigenous women.

METHODS

A cross-sectional study evaluating the prevalences of screening test results in indigenous women assisted in the Brazilian Amazon from 2007 to 2019 (3,231 tests), compared to non-indigenous women (698,415 tests). The main outcome was the cytological result. Other variables were frequency, age groups, and population. The frequency was categorized as "1st test", the first test performed by the women in their lifetime, or "screening test," tests from women who had previously participated in screening. Analyzes were based on prevalences by age group and population. We used Prevalence Ratios (PR) and 95% Confidence Intervals for risks and linear regression for trends.

RESULTS

Data from the 1st test showed a higher prevalence of Low-grade Squamous Intraepithelial Lesion (LSIL) in indigenous women. Peaks were observed in indigenous under 25, 35 to 39, 45 to 49, and 60 to 64. The prevalence of High-grade Squamous Intraepithelial Lesion or more severe (HSIL+) was low in both groups in women younger than 25. The indigenous HSIL+ prevalence curve showed a rapid increase, reaching peaks in women from 25 to 34 years, following a slight decrease and a plateau. In screening tests, HSIL+ was more prevalent in indigenous from 25 to 39 (PR 4.0,2.3;6.8) and 40 to 64 (PR 3.8,1.6;9.0). In indigenous, the PR of HSIL+ results in screening tests over 1st tests showed no screening effect in all age groups. In non-indigenous, there was a significant effect toward protection in the age groups over 25.

CONCLUSION

This screening study of indigenous women from diverse ethnicities showed a higher prevalence of cytological LSIL and HSIl+ than in non-indigenous women. The protective screening effect in reducing HSIL+ prevalence was not observed in indigenous.

Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study

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.

A population-based cross-sectional study on the situation of cervical cancer screening in Liaoning, China

Background

Cervical cancer (CC) screening is currently recognized as an effective intervention for CC. Previous studies found that the proportion of screening was low in China, especially in Liaoning. Therefore, we performed a population-based cross-sectional survey to investigate the situation of cervical cancer screening and analyze their related factors for providing a decision-making basis for sustainable and effective development of cervical cancer screening.

Methods

This population-based cross-sectional study involved aged 30 to 69 years in nine counties/districts in Liaoning from 2018 to 2019. Data were collected using the quantitative data collection methods, and analyzed in SPSS version 22.0.

Results

Overall, only 22.37% of 5334 respondents reported having ever been screened for cervical cancer in past 3 years, and 38.41% of respondents reported having the willingness for cervical cancer screening in next 3 years. In the rate of CC screening, multilevel analysis indicated that age, marital status, education level, type of occupation, medical insurance, family income, place of residence and regional economic level had a significant impact on proportion of screening. In the rate of CC screening willingness, multilevel analysis indicated that age, family income, health status, place of residence, regional economic level and CC screening still had a significant impact, but marital status, education level and medical insurance type had no significant impact. There was no significant difference in marital status, education level and medical insurance type after the factors of CC screening were added in the model.

Conclusion

Our study found both proportion of screening and willingness were at a low level, and age, economic and regional factors were the main factors for implementation of CC screening in China. In the future, targeted policies should be formulated according to the characteristics of different groups of people, and reduce the gap in the current health service capacity between different regions.

The Hybrid Capture 2 Results in Correlation with the Pap Test, Sexual Behavior, and Characteristics of Romanian Women

BACKGROUND

Human papillomavirus (HPV) infection is the major cause of cervical cancer (CC); hence, it is critical to understand the processes by which HPV infection causes squamous intraepithelial lesions, as well as the proper diagnostic tools. The objective of this study was to establish the correlations between Pap test results and Hybrid Capture 2 (HC2) tests findings.

MATERIALS AND METHODS

This study included 169 women between the ages of 30 and 64, who presented for consultation in gynecological clinics in both the public and the private sectors. These women reported symptoms, such as abnormal vaginal discharge and genital irritation, as well as early onset of sexual activity, multiple sexual partners, history of other sexually transmitted infections or high-risk sexual partners, immunosuppression, or tobacco smoking. Pap tests and HPV testing, using the HC2 method, were performed for the women enrolled in the study, including data gathered after patients completed questionnaires concerning their sexual behavior.

RESULTS

The HC2 method revealed that 66 patients (39.1%) tested positive for high-risk HPV types. Of the patients with positive results, 14 (21.2%) presented Atypical Squamous Cells of Undetermined Significance (ASC-US) compared to 10 (9.7%) patients in the negative group (p = 0.042). Atypical Squamous Cells for which a high-grade lesion cannot be excluded (ASC-H) were identified primarily in women with positive HC2 (6.1%). HR-HPV positivity was substantially more associated with low-grade ASC-US or low-grade squamous intraepithelial lesion (LSIL) and high-grade ASC-H cytology (OR = 2.53; 95% CI: 1.10-5.80, respectively, OR = 14.9; 95%CI: 1.006-34.59). Unmarried women (31.8%; p = 0.004) and women with multiple partners (over four partners, 10.6%; p = 0.03) were more likely to have an HPV infection when compared to married women and those with fewer sexual partners.

CONCLUSIONS

Understanding the epidemiology of HPV genital infections is essential for developing preventive measures against this infection and CC. Identifying the most prevalent HPV types, and determining the incidence of HPV oncogenic infections, in conjunction with Pap test results and sexual behavior information, can constitute part of an algorithm for the efficient management of cervical intraepithelial lesions.

HPV AND DNA METHYLATION TESTING IN URINE FOR CERVICAL INTRAEPITHELIAL NEOPLASIA AND CERVICAL CANCER DETECTION

BACKGROUND

Biomarker detection in urine offers a potential solution to increase effectiveness of cervical cancer screening programs by attracting non-responders. In this prospective study, the presence of high-risk human papillomavirus (hrHPV DNA) and the performance of DNA methylation analysis was determined for the detection of cervical cancer and high-grade cervical intraepithelial neoplasia (CIN2/3) in urine, and compared to paired cervicovaginal self-samples and clinician-taken cervical scrapes.

METHODS

A total of 587 samples were included from 113 women with cervical cancer, 92 women with CIN2/3, and 64 controls. Samples were tested for hrHPV DNA and five methylation markers. Univariate and multivariate logistic regression and leave-one-out cross-validation were used to determine the methylation marker performance for CIN3 and cervical cancer (CIN3+) detection in urine. Agreement between samples was determined using Cohen's kappa statistics and the Spearman correlation coefficients.

RESULTS

HrHPV presence was high in all sample types, 79% to 92%. Methylation levels of all markers in urine significantly increased with increasing severity of disease. The optimal marker panel (ASCL1/LHX8) resulted in an AUC of 0.84 for CIN3+ detection in urine, corresponding to an 86% sensitivity at a 70% predefined specificity. At this threshold 96%(109/113) of cervical cancers, 68%(46/64) of CIN3 and 58%(14/24) of CIN2 were detected. Between paired samples, a strong agreement for HPV16/18 genotyping and a fair to strong correlation for methylation was found.

CONCLUSION

HrHPV DNA and DNA methylation testing in urine offers a promising solution to detect cervical cancer and CIN2/3 lesions, especially for women currently unreached by conventional screening methods.

Advancing understanding of influences on cervical screening (non)-participation among younger and older women: A qualitative study using the theoretical domains framework and the COM-B model

BACKGROUND

Effective screening can prevent cervical cancer, but many women choose not to attend their screening tests.

OBJECTIVE

This study aimed to investigate behavioural influences on cervical screening participation using the Theoretical Domains Framework (TDF) and COM-B models of behaviour change.

DESIGN

A qualitative study and semistructured phone interviews were conducted with women invited for routine screening tests within the national cervical screening programme in Ireland.

SETTING AND PARTICIPANTS

Forty-eight women aged 25-65 years were recruited from the national screening register.

RESULTS

Seven core themes were identified that mapped to three COM-B components and 11 TDF domains: (1) knowledge of cervical cancer and screening, (2) coping with smear tests, (3) competing motivational processes-automatic and reflective, (4) cognitive resources, (5) role of social support, (6) environmental influences and (7) perceputal and practical influences. A range of knowledge about screening, perceived risk of cervical cancer and human papillomavirus infection was evident. Factors that influenced screening behaviours may be hierarchical-some were assigned greater importance than others. Positive screening behaviours were linked to autonomous motivation. Deficits in physical and psychological capability (inadequate coping skills) were barriers to screening, while physical and social opportunity (e.g. healthcare professional 'champions') could facilitate participation. Older women raised age-related issues (e.g. screening no longer necessary) and had more negative attitudes to screening, while younger women identified practical barriers.

CONCLUSIONS

This study provides insight into screening participation and will aid development of theoretically informed interventions to increase uptake.

PATIENT OR PUBLIC CONTRIBUTION

Women invited for screening tests through the national screening programme were interviewed. A Public & Patient Involvement (PPI) Panel, established to provide input into all CERVIVA research projects, advised the research team on recruitment materials and were given the opportunity to review and comment on the interview topic guide. This panel is made up of six women with various cervical screening histories and experiences.

Cancer screening at the level of state programs: review, recommendations and management

An overview of existing cancer screening programs, their organization system, and the main implementation parameters is presented. The methods of primary screening that have been shown to be effective in reducing mortality from certain cancers, as well as the reasons for the lack of screening programs in relation to some of them, are listed. The existing screening programs and their main characteristics are considered, and examples of using economic analysis to change screening programs are given. It is noted that in countries even with a large coverage, for example, in the United States and Germany, there is no single national register of screening, and the invitation system does not have a population-based nature. Although the large coverage and development of health systems in these countries allows for the positive effects of opportunistic screening, its effectiveness is lower than in countries with organized programs, and the costs are higher.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Time trends and age-period-cohort effects on the incidence of the most frequent cancers in Oran, Algeria, 1999-2018]

BACKGROUND

Cancer is currently one of the major public health problems in Algeria. The aim of this study was to examine time trends and the effects of age, period and cohort on incidence at the major cancer locations from 1999 to 2018 in Oran, Algeria.

METHODS

Data on the five most frequent primary cancer locations among patients aged 20-79 years were collected from the Oran cancer registry. Annual percentile changes in incidence rates were evaluated using the Joinpoint regression program. Age-period-cohort models were designed to examine the effects of age, period and birth cohort on cancer incidence.

RESULTS

From 1999 to 2018, there were 12,278 incident cases at the five major cancer locations. Unfavorable trends in incidence were observed regarding lung and colorectal cancers in both sexes, as well as breast cancer in women. Age-period-cohort analysis showed that age, period and birth cohort yielded different effects at different cancer locations.

CONCLUSION

The observed trends primarily reflect lifestyle changes in Algeria over the course of recent years.

Impact of knowledge and attitude on the utilization rate of cervical cancer screening tests among Ethiopian women: A systematic review and meta-analysis

INTRODUCTION

Cervical cancer is a major public health problem, particularly in resource-limited settings. The use of vaccination and screening tests has reduced the burden of cervical cancer in developed countries. However, the situation is quite the reverse in developing countries, including Ethiopia. Hence, this study aimed to estimate the pooled impact of knowledge and attitude on the prevalence of cervical cancer screening service utilization rates among Ethiopian women.

METHODS

Studies that examined cervical cancer screening service utilization among women in Ethiopia were searched from five international databases. Cochran's Q chi-square and the I-squared test statistics were used to check the presence of heterogeneity among the included studies. The funnel plot and Egger's regression tests were also used to assess the presence of publication bias. A weighted DerSimonian and Laird random-effects model was employed. Subgroup analysis was performed by the study population concerning the prevalence of cervical cancer screening service utilization rates. Sensitivity analysis was also conducted to assess the effect of a single study on the pooled estimates. Data analysis was performed using STATA™ Version 14 software.

RESULTS

A total of 44 studies with 28,186 study participants were included. The estimated pooled prevalence of cervical cancer screening service utilization was 8.11% (95% CI: 7.26, 8.97). After adjustment for publication bias with the trim and fill analysis, the estimated prevalence rate appeared to be 5.47% (95% CI: 4.66, 6.28). The prevalence of cervical cancer screening service utilization was higher among HIV-positive women, 16.85%, and in studies conducted among health care workers, 10.24%, than the general population. The pooled effect of knowledge on the utilization of cervical cancer screening tests among Ethiopian women was statistically significant (AOR = 3.20, 95% CI: 1.63, 6.31). Similarly, the pooled estimated odds of utilizing cervical cancer screening tests were 6.1 times higher (AOR = 6.09, 95% CI: 1.09, 34.36) among women who had a favorable attitude towards the screening tests.

CONCLUSION

Knowledge and attitude had a significant impact on the prevalence of cervical cancer screening test utilization rates among women in Ethiopia. However, the prevalence of cervical cancer screening service utilization among Ethiopian women is very low. Hence, large-scale awareness programs and situation-based strategies need to be designed to increase the uptake of cervical cancer screening services in the country.

Expanding the upper age limit for cervical cancer screening: a protocol for a nationwide non-randomised intervention study

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.

Comparison of the detection rate of cervical lesion with TruScreen, LBC test and HPV test: A Real-world study based on population screening of cervical cancer in rural areas of China

BACKGROUND AND OBJECTIVE

China carries a heavy burden of cervical cancer and has an alarmingly low cervical cancer screening rate. In order to achieve the goal of cervical cancer elimination, there is an urgent need for suitable methods and strategies in China.

MATERIALS AND METHODS

A total 9972 woman who received cervical cancer screening services of National Cervical Cancer Screening Program in Rural Areas (NCCSPRA) in 8 project counties participated in this study. TruScreen, HPV test and LBC test were performed in all participants. A total of 1945women had one or more than one positive or abnormal screening results of the above three screening tests subsequently received colposcopy. The detection rate of CIN2+ between the three tests were compared.

RESULTS

No matter what kind of screening method is used, the CIN2+ detection rate in the eastern regions was much higher than that in the central and western regions. The total detection rate of CIN2+ in HPV group was highest (0.73%), following in LBC group (0.44%) and TS group (0.31%). There was statistically significant difference in the total detection rate of CIN2+ between TS and HPV groups, LBC and HPV groups, respectively. There was no statistical difference in the total detection rate of CIN2+ between TS and LBC screening groups. Moreover, except for the eastern regions, there was no statistical difference in the detection rate of CIN2+ between TS group and the other two groups in central and western regions.

CONCLUSION

If it can meet the requirements of the laboratory and personnel, HPV test seems to be the preferred method for cervical cancer screening in rural areas of China. The characteristics of minimal training requirements, simple operation, real-time results obtained without the collection of cervical cell samples and the help of laboratory equipment and cytologists of TS make it ideal for cervical cancer screening in low-resource regions.

Reasons for low cervical cancer survival in new accession European Union countries: a EUROCARE-5 study

PURPOSE

With better access to early diagnosis and appropriate treatment, cervical cancer (CC) burden decreased in several European countries. In Eastern European (EE) countries, which accessed European Union in 2004, CC survival was worse than in the rest of Europe. The present study investigates CC survival differences across five European regions, considering stage at diagnosis (local, regional and metastatic), morphology (mainly squamous versus glandular tumours) and patients' age.

METHODS

We analysed 101,714 CC women diagnosed in 2000-2007 and followed-up to December 2008. Age-standardised 5-year relative survival (RS) and the excess risks of cancer death in the 5 years after diagnosis were computed.

RESULTS

EE women were older and less commonly diagnosed with glandular tumours. Proportions of local stage cancers were similar across Europe, while morphology- and stage-specific RS (especially for non-metastatic disease) were lower in Eastern Europe. Adjusting for age and morphology, excess risk of local stage CC death for EE patients remained higher than that for other European women.

CONCLUSION

Stage, age and morphology alone do not explain worse survival in Eastern Europe: less effective care may play a role, probably partly due to fewer or inadequate resources being allocated to health care in this area, compared to the rest of Europe.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Pap tests for cervical cancer screening test and contraception: analysis of data from the CONSTANCES cohort study

BACKGROUND

In France, a Pap test for cervical cancer screening is recommended every three years for all sexually active women aged 25 to 65 years. Modes of contraception (any or no contraception, with or without a visit to a physician, and with or without a gynecological examination) may influence adhesion to screening: women who use intrauterine device (IUD) should be more up to date with their cervical cancer screening more often than those using other means of contraception. Our objectives were to analyze the association between modes of contraception and Pap tests for screening.

METHODS

This cross sectional study is based on the CONSTANCES cohort enabled us to include 16,764 women aged 25-50 years. The factors associated with adhesion to cervical cancer screening (defined by a report of a Pap test within the previous 3 years) was modeled by logistic regression. Missing data were imputed by using multiple imputations. The multivariate analyses were adjusted for sex life, social and demographic characteristics, and health status.

RESULTS

Overall, 11.2% (1875) of the women reported that they were overdue for Pap test screening. In the multivariate analysis there was no significant difference between women using an IUD and those pills or implant of pap test overdue ORa:0.9 CI95% [0.8-1.1], ORa 1.3 CI95% [0.7-2.7] respectively. Women not using contraceptives and those using non-medical contraceptives (condoms, spermicides, etc.) were overdue more often ORa: 2.6 CI95% [2.2-3.0] and ORa: 1.8 CI95% [1.6-2.1] respectively than those using an IUD.

CONCLUSION

Women seeing medical professionals for contraception are more likely to have Pap tests.

Invitation strategies and coverage in the population-based cancer screening programmes in the European Union

The aim of this study was to describe the compliance of the population-based cancer screening programmes in the European Union Member States to the invitation strategies enumerated in the European Guidelines and the impact of such strategies on the invitational coverage. Experts in screening programme monitoring from the respective countries provided data. Coverage by invitation was calculated as the proportion of individuals in the target age range receiving a screening invitation over the total number of annualized eligible population. The invitation strategies of 30 breasts, 25 cervical and 27 colorectal national or regional population-based screening programmes are described. Individual mail invitations are sent by 28 breasts, 20 cervical and 25 colorectal screening programmes. Faecal occult blood test kits are sent by post in 17 of the colorectal cancer screening programmes. The majority of programmes claimed to have a population registry, although some use health insurance data as the database for sending invitations. At least 95% invitation coverage was reached by 16 breast, six cervical and five colorectal screening programmes. Majority of the programmes comply with the invitation strategies enumerated in the European guidelines, although there is still scope for improvements. Coverage by invitation is below the desirable level in many population-based cancer screening programmes in European Union.

Establishment of a national cervical screening programme in Ireland, CervicalCheck: the first 6 years

The national cervical screening programme, CervicalCheck, commenced in Ireland in 2008. Free cervical smear tests are offered to over 1.2 million women aged 25-60 every 3 (aged 25-44) and 5 (aged 45-60) years. The purpose of this paper is to highlight the achievements and document the experience of the first 6 years of a new cervical screening programme. Data were extracted from the programme screening register and colposcopy management systems. SAS, version 9.4 was used for statistical analysis. Over 1.98 million smear tests were performed in over 1 million women during the first 6 years of the programme. Overall 5-year coverage at the end of the sixth year was 77.0%, where coverage is presented for the target population of women aged 25-60 years and is adjusted for hysterectomy rates. The numbers of women attending colposcopy increased significantly from 10 000 new patients attending for the first time in the first year to a peak of almost 17 500 in the third year. Increased capacity in colposcopy has delivered significant improvements in waiting times; the percentage of women referred to colposcopy offered an appointment within 8 weeks increased from 41.5% in year 1 to 93.4% in year 4 and has remained above the greater than 90% standard thereafter. The number of biopsies increased markedly, with 33 768 women being diagnosed with cervical intraepithelial neoplasia-grade 2 (CIN2), CIN3 or adenocarcinoma in situ and 860 being diagnosed with invasive cancer by the end of the sixth year. Lessons from CervicalCheck include the importance of capacity planning in programme delivery. The programme continues to evolve, particularly with the increased usage of human papillomavirus testing and planning for future testing of the human papillomavirus (HPV)-vaccinated cohort.

Key indicators of organized cancer screening programs: Results from a Delphi study

Objective

To maximize benefits and reduce potential harms of organized cancer screening programs in Europe, monitoring, quality assurance, and evaluation of long-term impact are required. We aimed to identify the most important indicators to be collected and reported. The study was designed to establish a consensus within a European-level working group and suggest a manageable list of key indicators.

Methods

We conducted a Delphi study among policymakers, researchers, and program coordinators who were experts in breast, cervical, or colorectal cancer screening. Study participants evaluated the importance of screening indicators on a 5-point Likert scale.

Results

The top 10 indicators by study participants were interval cancer rate, detection rate, screening attendance, screening coverage, cancer incidence, cause-specific mortality, proportion of persons attending further assessment after a positive screen test result, proportion of persons attending a treatment after diagnosis, invitation coverage, and distribution of cancers by mode of detection. Performance indicators were generally considered more important than outcome indicators. Subgroup analyses by cancer types showed similar results, and only cervical cancer screening experts had slightly different preferences. Subgroup analyses by experts’ roles indicated that policymakers found different indicators important compared with researchers or program coordinators, probably because of their different point of view on screening.

Conclusion

The implication of our priority ranking is twofold: it serves as an initial guidance for countries that have not yet established a system to collect data, and as a checklist for those where data collection is already established, to assess the comprehensiveness of their system.

Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial

Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.

Cervical Cancer Screening Programs in Europe: The Transition Towards HPV Vaccination and Population-Based HPV Testing

Cervical cancer is the fourth most frequently occurring cancer in women around the world and can affect them during their reproductive years. Since the development of the Papanicolaou (Pap) test, screening has been essential in identifying cervical cancer at a treatable stage. With the identification of the human papillomavirus (HPV) as the causative agent of essentially all cervical cancer cases, HPV molecular screening tests and HPV vaccines for primary prevention against the virus have been developed. Accordingly, comparative studies were designed to assess the performance of cervical cancer screening methods in order to devise the best screening strategy possible. This review critically assesses the current cervical cancer screening methods as well as the implementation of HPV vaccination in Europe. The most recent European Guidelines and recommendations for organized population-based programs with HPV testing as the primary screening method are also presented. Lastly, the current landscape of cervical cancer screening programs is assessed for both European Union member states and some associated countries, in regard to the transition towards population-based screening programs with primary HPV testing.

Estimating the impact of an organised screening programme on cervical cancer incidence: A 26-year study from northern Italy

The impact of the organised cervical cancer (CC) screening programmes implemented in Europe since the 1990s has been insufficiently evaluated. We investigated the changes in CC incidence following the introduction of a screening programme in the Emilia-Romagna Region (northern Italy). The study period was 1988-2013. The programme, targeting women aged 25-64 years (1,219,000 in 2018), started in 1998. The annual incidence rates that would be expected in 1998-2013 in the absence of screening were estimated, first, by analysing the annual rates in 1988-1997 with a log-linear model and, second, by analysing the annual rates in 1988-2013 with an age-period model in which the period effect was enforced to be linear. Cervical adenocarcinoma incidence trend over the entire period was used to validate both estimates. Observed annual rates were compared to the two series of expected ones with the incidence rate ratio (IRR). Incidence remained stable during 1988-1997, peaked in 1998 and then decreased until 2007, when it stabilised. The two series of expected rates were virtually coincident and their trends roughly paralleled the stable adenocarcinoma incidence trend. After 2007, the median IRR was 0.60 (95% confidence interval, 0.45-0.81) based on the log-linear model and 0.58 (95% confidence interval, 0.34-0.97) based on the age-period model. Thirty-six to seventy-five CC cases were prevented annually for an average annual frequency of 6.5 per 100,000 women in the target population. In summary, consistent circumstantial evidences were obtained that the organised screening programme brought about a 40% reduction in annual CC incidence after 10 years.

Não realização de citopatológico de colo uterino entre gestantes no extremo sul do Brasil: prevalência e fatores associados

Resumo O câncer do colo do útero é o terceiro tumor mais frequente na população feminina e o teste citopatológico (CP) a principal estratégia para o rastreamento. Este estudo mediu a prevalência e os fatores associados à não realização de CP entre gestantes maiores de 25 anos, durante o pré-natal, no município de Rio Grande, RS, em 2013. A análise multivariável utilizou regressão de Poisson avaliada por meio de razão de prevalências (RP). Dentre as 1474 gestantes incluídas no estudo, 21,6% (IC95% 19,5%-23,7%) não realizaram CP nos últimos três anos. Na análise ajustada, a RP para não realização entre puérperas com escolaridade entre 0-4 anos foi 2,14 (IC95%:1,35-3,38) em comparação àquelas com 12 anos ou mais. Ter referido aborto prévio e consumido álcool durante a gestação mostrou RP = 1,38 (1,10-1,73) e 1,39 (1,04-1,84) de não fazê-lo em relação às demais, respectivamente. Realizar 1-5 consultas de pré-natal conferiu RP = 1,35 (1,03-1,77) em relação às demais. Evidencia-se proporção expressiva de não realização de CP e não cumprimento de recomendação básica do Ministério da Saúde. Os profissionais de saúde deveriam reforçar a necessidade de realização deste exame, bem como busca ativa na comunidade das gestantes com o perfil aqui descrito.

Identifying the barriers to effective breast, cervical and colorectal cancer screening in thirty one European countries using the Barriers to Effective Screening Tool (BEST)

The aim of this study was to identify barriers to effective breast, cervical and colorectal cancer screening programmes throughout the whole of the European region using the Barriers to Effective Screening Tool (BEST). The study was part of the scope of the EU-TOPIA (TOwards imProved screening for breast, cervical and colorectal cancer In All of Europe) project and respondents were European screening organisers, researchers and policymakers taking part in a workshop for the project in Budapest in September 2017. 67 respondents from 31 countries responded to the online survey. The study found that there are many barriers to effective screening throughout the system from identification of the eligible population to ensuring appropriate follow-up and treatment for the three cancers. The most common barriers were opportunistic screening, sub-optimal participation, limited capacity (including trained human resource), inadequate and/or disjointed information technology systems and complex administration procedures. Many of the barriers were reported consistently across different countries. This study identified the barriers that, in general, require further investment of resources.

Cervical Cytology Biobanking in Europe

A cervical cytology biobank (CCB) is an extension of current cytopathology laboratory practice consisting in the systematic storage of Pap smears or liquid-based cytology samples from women participating in cervical cancer screening with the explicit purpose to facilitate future scientific research and quality audit of preventive services. A CCB should use an internationally agreed uniform cytology terminology, be integrated in a national or regional screening registry, and be linked to other registries (histology, cancer, vaccination). Legal and ethical principles concerning personal integrity and data safety must be respected strictly. Biobank-based studies require approval of ethical review boards.

A CCB is an almost inexhaustible resource for fundamental and applied biological research. In particular, it can contribute to answering questions on the natural history of HPV infection and HPV-induced lesions and cancers, screening effectiveness, exploration of new biomarkers, and surveillance of the short- and long-term effects of the introduction of HPV vaccination. To understand the limitations of CCB, more studies are needed on the quality of samples in relation to sample type, storage procedures, and duration of storage.

Performance indicators in a newly established organized cervical screening programme: registry-based analysis in the Czech Republic

In 2008, the organized Czech National Cervical Cancer Screening Programme (CNCCSP) was initiated by transformation of the existing opportunistic efforts. The aim of our study was to examine recent cervical cancer burden trends and to assess the quality of the Czech National Cervical Cancer Screening Programme using a set of standard performance indicators. Our study utilized data from the national Cervical Cancer Screening Registry and the Czech National Cancer Registry. We computed internationally accepted indicators and assessed time trends and variability among screening centres. Between 1995 and 2011, the incidence of age-standardized cervical cancer decreased by 21% (1023 cases in 2011), and the mortality decreased by 35% (399 deaths in 2011). The annual coverage of the target population by cervical screening increased to 56% in 2013 (as compared with 35% in 2001). If we consider a 2-year interval (2012-2013), the estimated coverage was 77%. Over two million women underwent screening in 2013; 96% of them had a negative result. About 0.2% of smears showed cytological signs of a high-grade intraepithelial lesion or a malignancy, and the estimated positive predictive value for advanced intraepithelial neoplasia (cervical intraepithelial neoplasia grade 2+) was 79.6%. However, performance indicators show considerable heterogeneity between screening centres. The reported values of performance indicators are in line with the results of programmes that have previously been shown to be successful in terms of decreasing the cervical cancer burden, and are promising with respect to an even more pronounced decrease in cervical cancer mortality in the near future, provided that continuous quality improvement can be maintained. Linkage studies between screening, cancer and cause-of-death registers can provide further information on screening effectiveness and validity issues.

Effect of Cervical Cancer Screening Programs on Preterm Birth: A Decision and Cost-Effectiveness Analysis

OBJECTIVE

To assess the effect of age at initiation and interval of cervical cancer screening in women of reproductive age on the risk of future preterm birth and subsequent adverse neonatal outcome relative to maternal life-years gained and cost of both screening and preterm birth.

METHODS

In this decision and cost-effectiveness analysis, we compared eight cytology-based screening programs varying in age of onset (21, 24, 25, 27, or 30 years) and screening interval (3 or 5 years) in a fictive cohort of 100,000 women. We used the microsimulation screening analysis model to estimate number of cervical intraepithelial neoplasia diagnoses, large loop excisions of the transformation zone (LLETZs), life-years gained, cervical cancer cases, deaths, and costs of screening and treatment. We used the number of LLETZs to calculate additional preterm births, subsequent neonatal morbidity, mortality, and associated costs.

RESULTS

The number of LLETZs per 100,000 women varied from 9,612 for the most intensive screening (every 3 years from age 21 years) to 4,646 for the least intensive screening (every 5 years from age 30 years). Compared with the least intensive program, the most intensive program increased maternal life-years gained by 9% (10,728 compared with 9,839), decreased cervical cancer cases by 67% (52 compared with 158), and cervical cancer deaths by 75% (four compared with 16) at the expense of 250% (158 compared with 45) more preterm births and 320% (four compared with one) more neonatal deaths while increasing total costs by $55 million ($77 compared with $23 million). The number of maternal life-years gained per additional preterm birth varied from 68 to 258 with subsequent total costs per maternal life-years gained of $7,212 and $2,329.

CONCLUSION

Cervical cancer screening every 3 years and subsequent treatment in women aged younger than 30 years yield limited life-years but may have substantial perinatal adverse effects. Consequently, women who plan to have children may benefit from a more cautious screening approach, taking into account their risk for both cancer and preterm birth.

Health-related quality of life as measured by the EQ-5D in the prevention, screening and management of cervical disease: A systematic review

PURPOSE

Cost-effectiveness analyses (CEAs) of screening can be highly sensitive to the health-related quality of life (HRQoL) effects of screen tests and subsequent treatment. Accordingly, accurate assessment of HRQoL is essential. We reviewed the literature regarding HRQoL in cervical prevention and management in order to appraise the current evidence regarding this important input to CEA.

METHODS

We searched the MEDLINE, Scopus and EconLit databases for studies that estimated HRQoL in cervical cancer prevention and management published January 1995-December 2015. The primary inclusion criterion was for studies that assess HRQoL using the EQ-5D. Data were abstracted from eligible studies on setting, elicitation group, sample size, elicitation instruments, health state valuations, study design and follow-up. We assessed the quality and comparability of the studies with a particular focus on the HRQoL reported across states and groups.

RESULTS

Fifteen papers met the inclusion criteria. Most used patient elicitation groups (n = 11), 2 used the general public and 2 used a mix of both. Eight studies were cross-sectional and seven were longitudinal. Six studies used both the EQ-5D-3L and the EQ-VAS together with other measures of overall HRQoL or condition-specific instruments. Extensive heterogeneity was observed across study characteristics.

CONCLUSIONS

Our results reveal the challenges of sourcing reliable estimates of HRQoL for use in CEAs of cervical cancer prevention and treatment. The EQ-5D appears insufficiently sensitive for some health states. A more general problem is the paucity of HRQoL estimates for many health states and their change over time.

Self-collected cervicovaginal sampling for site-of-care primary HPV-based cervical cancer screening: a pilot study in a rural underserved Greek population

In the present pilot study, the feasibility of a site-of-care cervicovaginal self-sampling methodology for HPV-based screening was tested in 346 women residing in underserved rural areas of Northern Greece. These women provided self-collected cervicovaginal sample along with a study questionnaire. Following molecular testing, using the cobas^® HPV Test, Roche^®, HPV positive women, were referred to colposcopy and upon abnormal findings, to biopsy and treatment. Participation rate was 100%. Regular pap-test examination was reported for 17.1%. Among hrHPV testing, 11.9% were positive and colposcopy/biopsy revealed 2 CIN3 cases. Non-compliance was the most prevalent reason for no previous attendance. Most women reported non-difficulty and non-discomfort in self-sampling (77.6% and 82.4%, respectively). They would choose self-sampling over clinician-sampling (86.2%), and should self-sampling being available, they would test themselves more regularly (92.3%). In conclusion, self-sampling is feasible and well-accepted for HPV-based screening, and could increase population coverage in underserved areas, helping towards successful prevention.

The influence of total hysterectomy in a cervical cancer screening population: a register-based cross-sectional study

BACKGROUND

High coverage of a screening program is essential to program success. Many European screening programs cover only 10-80% of their target population. A possible explanation for the low coverage may be that some women in the screening population have had a total hysterectomy, thus they are not at risk of cervical cancer. The aim of this study was to identify the prevalence of hysterectomy in the target population of the Danish National Cervical Cancer Screening Program (NCCSP) and to recalculate coverage after excluding women with total hysterectomy. Furthermore, to analyze the association between hysterectomy and sociodemographic factors within the screening population.

METHODS

A population-based cross-sectional study using register data on all women in the target population of the NCCSP on January 12, 2012 (women born January 12, 1947, to January 12, 1986). The total coverage included women with hysterectomy in the target population whereas the recalculated coverage was calculated excluding women with total hysterectomy. To test the differences between the total coverage and the recalculated coverage, a two-sample z-test between the proportion of covered hysterectomized women and the proportion of covered non-hysterectomised women were used. A logistic regression model adjusted for age and sociodemographic characteristics was used to analyze the association between sociodemographic factors and total hysterectomy.

RESULTS

The coverage among women aged 26-49 years and 55-64 years were 77.4% and 72.7%, respectively. The recalculated coverage was 78.2% (26-49 years) and 79.4% (55-64 years). Recalculating the coverage did not result in coverage higher than 82.7% at any age. The effect of excluding women with total hysterectomy increased with age, reaching its maximum of 8 % points for the oldest women. Women with higher socioeconomic status (higher education and higher disposable income) had lower odds of being hysterectomized compared to other women. Also, immigrants and descendants had lower odds of being hysterectomized compared to ethnic Danes.

CONCLUSIONS

Excluding women with total hysterectomy only partly explained the low coverage of the NCCSP. Thus, initiatives must be made to improve acceptability of and accessibility to the NCCSP, especially in the youngest and the oldest women.

Invitation coverage and participation in Italian cervical, breast and colorectal cancer screening programmes

Objectives

In Italy, regional governments organize cervical, breast and colorectal cancer screening programmes, but there are difficulties in regularly inviting all the target populations and participation remains low. We analysed the determinants associated with invitation coverage of and participation in these programmes.

Methods

We used data on screening programmes from annual Ministry of Health surveys, 1999–2012 for cervical, 1999–2011 for breast and 2005–2011 for colorectal cancer. For recent years, we linked these data to the results of the national routine survey on preventive behaviours to evaluate the effect of spontaneous screening at Province level. Invitation and participation relative risk were calculated using Generalized Linear Models.

Results

There is a strong decreasing trend in invitation coverage and participation in screening programmes from North to South Italy. In metropolitan areas, both invitation coverage (rate ratio 0.35–0.96) and participation (rate ratio 0.63–0.88) are lower. An inverse association exists between spontaneous screening and both screening invitation coverage (1–3% decrease in invitation coverage per 1% spontaneous coverage increase) and participation (2% decrease in participation per 1% spontaneous coverage increase) for the three programmes. High recall rate has a negative effect on invitation coverage in the next round for breast cancer (1% decrease in invitation per 1% recall increase).

Conclusions

Organizational and cultural changes are needed to better implement cancer screening in southern Italy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01373723 .

Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities

Background: Incidence and mortality of cervical cancer declined thanks to Pap smear screening. However cervical cancer screening (CCS) inequalities are documented, including in high income countries. This population-based study aims to assess the importance and 20-year trends of CCS inequalities in Switzerland, where healthcare costs and medical coverage are among the highest in the world. Methods: We analyzed data from five waves of the population-based Swiss Health Interview Survey (SHIS) covering the period 1992–2012. Multivariable Poisson regression were used to estimate weighted prevalence ratios (PR) of CCS and 95% Confidence Intervals (CI) adjusting for socio-economic, socio-demographic characteristics, family status, health status, and use of healthcare. Results: The study included 32’651 women aged between 20 and 70 years old. Between 1992 and 2012, rates of CCS over the past 3 years fluctuated between 71.7 and 79.6% (adjusted P < 0.001). Lower CCS was observed among women with low education, low income, those having limited emotional support, who were non-Swiss, single, older, living in non-metropolitan area or in the French-speaking region, overweight. Over the analyzed period, differences in CCS across age groups diminished while rates among women who visited a GP over the previous year, versus those who did not, increased. Conclusions : While important changes occurred in screening recommendations and in social circumstances of the targeted population, CCS rates remained fairly stable in Switzerland between 1992 and 2012. At the same time, inequalities in CCS persisted over that period.

High lifetime probability of screen-detected cervical abnormalities

Objective

Regular screening and follow-up is an important key to cervical cancer prevention; however, screening inevitably detects mild or borderline abnormalities that would never progress to a more severe stage. We analysed the cumulative probability and recurrence of cervical abnormalities in the Finnish organized screening programme during a 22-year follow-up.

Methods

Screening histories were collected for 364,487 women born between 1950 and 1965. Data consisted of 1 207,017 routine screens and 88,143 follow-up screens between 1991 and 2012. Probabilities of cervical abnormalities by age were estimated using logistic regression and generalized estimating equations methodology.

Results

The probability of experiencing any abnormality at least once at ages 30–64 was 34.0% (95% confidence interval [CI]: 33.3–34.6%). Probability was 5.4% (95% CI: 5.0–5.8%) for results warranting referral and 2.2% (95% CI: 2.0–2.4%) for results with histologically confirmed findings. Previous occurrences were associated with an increased risk of detecting new ones, specifically in older women.

Conclusion

A considerable proportion of women experience at least one abnormal screening result during their lifetime, and yet very few eventually develop an actual precancerous lesion. Re-evaluation of diagnostic criteria concerning mild abnormalities might improve the balance of harms and benefits of screening. Special monitoring of women with recurrent abnormalities especially at older ages may also be needed.

Trends of incidence rate and age at diagnosis for cervical cancer in China, from 2000 to 2014

Objective

To analyze the trends of incidence rate and age at diagnosis for cervical cancer incidence in China using population-based cancer registration data from 2000 to 2014.

Methods

Data were from National Central Cancer Registry of China. Crude incidence rates (CIRs), age-specific incidence rate, age-standardized incidence rates (ASIRs), age percentage distribution, standardized age percentage distribution, mean age at diagnosis and standardized mean age at diagnosis for cervical cancer in all areas of China, urban China and rural China were calculated separately. The world Segi's population was applied to remove the age structure influence. Joinpoint regression was performed to obtain average annual percent change (AAPC) and age-period-cohort analysis was used to examine the incidence trends.

Results

CIRs and ASIRs for cervical cancer increased in China from 2000 to 2014. The AAPC of ASIRs in China was at 9.2% [95% confidence interval (95% CI): 7.0%-11.5%, P<0.05], and the AAPC in rural areas was relatively high. The age-specific incidence rate in groups aged 0-69 years have significantly increased over time. Groups aged 40-69 years showed the highest incidence risk, and the annual percent changes (APCs) of incidence rate in groups aged 40-59 years in urban China and groups aged 0-49 years in rural China were more than 10%. For each age group, the urban-to-rural incidence rate ratios (IRRs) got close to 1 over time. There were clear birth cohort effects in successive generations born from 1940 to 1970 in China. In rural China, the standardized mean age at diagnosis had significantly declined by 5.18 years. In China, the main peak and secondary peak of standardized age percentages appeared in the groups aged 45-49 and 40-44 years, respectively. In rural China, the main peak of standardized age percentage moved from the group aged 55-59 years to the group aged 45-49 years, and the standardized age percentages of groups aged 25-34 years also increased. In China, the standardized age percentages has significantly increased in groups aged 35-64 and 30-64 years over time, and accounted for about 80% and 85% in 2014, respectively.

Conclusions

The cervical cancer incidence increased in China and the gap of incidence between urban and rural China was narrowed. The trends of increasing cervical cancer incidence among younger women existed in China, especially in rural China. A more appropriate screening, vaccination and health education strategies should be established.

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

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

Effect of pay-for-performance on cervical cancer screening participation in France

Pay-for-performance (P4P) has been increasingly used across different healthcare settings to incentivize the provision of targeted services. In this study, we investigated the effect of a nationwide P4P scheme for general practitioners implemented in 2012 in France, on cervical cancer screening practices. Using data from a nationally representative permanent sample of health insurance beneficiaries, we analyzed smear test use of eligible women for the years 2006-2014. Our longitudinal sample was an unbalanced panel comprising 180,167 women eligible from 1 to 9 years each. We took into account that during our study period some women were exposed to another incentive for screening participation: the implementation in 2010 of organized screening (OS) in a limited number of areas. To evaluate the effect of P4P, we defined three different measures of smear utilization. For each measure, we specified binary panel-data models to estimate annual probabilities and to compare each estimate to the 2011 baseline level. To explore the combined effect of P4P and OS in areas exposed to both incentives, we computed interaction terms between year dummies and area of residence. We found that P4P had a modest positive effect on recommended screening participation. This effect is likely to be transient as annual smear use, both for the whole sample and among women overdue for screening, increased only in 2013 and decreased again in 2014. The combined effect of P4P and OS on screening participation was not cumulative during the first years of coexistence.

Study protocol of the CHOiCE trial: a three-armed, randomized, controlled trial of home-based HPV self-sampling for non-participants in an organized cervical cancer screening program

BACKGROUND

The effectiveness of cervical cancer screening programs is challenged by suboptimal participation and coverage. Offering cervico-vaginal self-sampling for human papillomavirus testing (HPV self-sampling) to non-participants can increase screening participation. However, the effect varies substantially among studies, especially depending on the approach used to offer HPV self-sampling. The present trial evaluates the effect on participation in an organized screening program of a HPV self-sampling kit mailed directly to the home of the woman or mailed to the woman's home on demand only, compared with the standard second reminder for regular screening.

METHODS/DESIGN

The CHOiCE trial is a parallel, randomized, controlled, open-label trial. It will include 9327 women aged 30-64 years who are living in the Central Denmark Region and who have not participated in cervical cancer screening after an invitation and one reminder. The women will be equally randomized into three arms: 1) Directly mailed a second reminder including a HPV self-sampling kit; 2) Mailed a second reminder offering a HPV self-sampling kit, to be ordered by e-mail, text message, phone, or through a webpage; and 3) Mailed a second reminder for a practitioner-collected sample (control group). The primary outcome will be the proportion of women in the intervention groups who participate by returning their HPV self-sampling kit or have a practitioner-collected sample compared with the proportion of women who have a practitioner-collected sample in the control group at 90 and 180 days after mail out of the second reminders. Per-protocol and intention-to-treat analyses will be performed. The secondary outcome will be the proportion of women with a positive HPV self-collected sample who attend follow-up testing at 30, 60, or 90 days after mail out of the results.

DISCUSSION

The CHOiCE trial will provide strong and important evidence allowing us to determine if and how HPV self-sampling can be used to increase participation in cervical cancer screening. This trial therefore has the potential to improve prevention and reduce the number of deaths caused by cervical cancer.

TRIAL REGISTRATION

Current Controlled Trials NCT02680262 . Registered 10 February 2016.

Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer

OBJECTIVE

Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC.

METHODS

We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results.

RESULTS

We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran.

CONCLUSION

We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.

Registry-based assessment of the status of cervical screening in Sweden

OBJECTIVES

Comprehensive nationwide monitoring and evaluation of screening through registry-based review of key indicators is necessary for programme optimization, especially as new tests and strategies are introduced. We aimed to investigate and report on the use of these key indicators in the Swedish programme.

SETTING AND METHODS

Organized population-based cervical screening targeting women aged 23-50 and 51-60 every three and five years, respectively, is regionally implemented in Sweden. All cytological and histopathological test results and invitations are exported to the National Cervical Screening Registry. We describe the methods to obtain registry-based quality indicators by age, region, and calendar period.

RESULTS

In 2013, there were 633,592 cervical smears in Sweden, of which 69% were organized smears resulting from an invitation. Screening test coverage for women aged 23-60 was 80% and similar for the previous decade, but varied greatly between and within counties over-time. Among women aged 23-25, test coverage increased dramatically during the previous six years, reaching 87% in 2013. The proportion of women with cytological high-grade cervical lesions found in cytology that had been followed-up with biopsy within one year was 97%. Major variations in cervical cancer incidence between counties were observed.

CONCLUSIONS

Registry-based analyses of key quality indicators provided the basis for prioritizing improvements of the organized cervical screening programme.

The potential harms of primary human papillomavirus screening in over-screened women: a microsimulation study

BACKGROUND

It is well acknowledged that HPV testing should not be performed at young age and at short intervals. Cytological screening practices have shown that over-screening, i.e., from a younger age and at shorter intervals than recommended, is hard to avoid. We quantified the consequences of a switch to primary HPV screening for over-screened women, taking into account its higher sensitivity but lower specificity than cytology.

METHODS

The health effects of using the HPV test instead of cytology as the primary screening method were determined with the MISCAN-Cervix model. We varied the age women start screening and the interval between screens. In the sensitivity analyses, we varied the background risk of cervical cancer, the HPV prevalence, the discount rate, the triage strategy after cytology, and the test characteristics of both cytology and the HPV test.

RESULTS

For women screened 5 yearly from age 30, 32 extra deaths per 100,000 simulated women were prevented when switching from primary cytology to primary HPV testing. For annual screening from age 20, such a switch resulted in 6 extra deaths prevented. It was associated with 9,044 more positive primary screens in the former scenario versus 76,480 in the latter. Under all conditions, for women screened annually, switching to HPV screening resulted in a net loss of quality-adjusted life years.

CONCLUSION

For over-screened women, the harms associated with a lower test specificity outweigh the life years gained when switching from primary cytology to primary HPV testing. The extent of over-screening should be considered when deciding on inclusion of primary HPV screening in cervical cancer screening guidelines.

HEALTH SURVEILLANCE AND PAP TEST COVERAGE: INTEGRATIVE REVIEW

ABSTRACT This integrative review aimed to evidence in the literature health surveillance activities that contribute to the increased coverage of the cervical Pap smear. The search was undertaken between April and May 2014 in the databases LILACS, CINAHL, MEDLINE and Scopus, using the keywords health surveillance, cervix neoplasm prevention, and Papanicolaou test, in Portuguese, English and Spanish. We selected 341 articles, of which 33 met the inclusion criteria. In studies, the actions have been identified and grouped according to two main control practices of cervical cancer adopted in Brazil: primary prevention and secondary prevention, with emphasis on health promotion and prevention actions that contributed to the increased coverage of the cervical Pap smear.

Knowledge of Cervical Cancer Screening among Women across Different Socio-Economic Regions of China

Background and Objective

China has a high burden of cervical cancer (CC) and wide disparities in CC burden exist among different socio-economic regions. In order to reduce these disparities, China’s government launched the National Cervical Cancer Screening Program in Rural Areas (NCCSPRA) in 2009. Understanding the factors associated with underutilization of CC screening among target populations is important to improve the screening participation rate, and a high participation rate is key to achieving the goals of a screening program. However, data on the knowledge of CC among target populations in program areas is lacking in China. This study will investigate the knowledge of CC prevention and control among women in specific project counties to develop a better understanding of factors that might influence CC screening participation in order to improve the implementation of the NCCSPRA.

Materials and Methods

A cross-sectional survey was conducted and face-to-face interview questionnaires were completed by 308 women who received CC screening services in 6 project counties of NCCSPRA across different socio-economic regions of China. ANOVA and Chi-square tests were used to compare the knowledge rates and scores across the different subgroups. Logistic regression was conducted to examine factors associated with knowledge level.

Results

The overall CC knowledge rate of the target population was only 19.5%. Regional socio-economic level, advice from doctors, age, and educational status were strong predictors of knowledge level of CC screening. Significantly lower knowledge rates and scores were identified in older women (55–64 years old), less educated women (with primary school or illiterate), women in less developed regions and women who did not receive any advice about screening results from doctors.

Conclusion

The knowledge of CC screening among women in the project counties of NCCSPRA was found to be very poor. Given the importance of knowledge in encouraging women to participate in screening is key to reducing CC burden in rural women in China, it is urgent that a targeted health promotion intervention is developed and implemented in project counties, especially targeting older women, women with less education and women in less developed regions, and focus on improving their CC knowledge and encouraging them to communicate with health care providers. The health promotion intervention targeting health care providers is also important to improve their knowledge of CC and provide best advice to women.

Cervical carcinoma in the European Union: an update on disease burden, screening program state of activation, and coverage as of March 2014

OBJECTIVE

Cervical cancer (CC) is defined as a disease of disparity. This is due to marked differences in CC incidence and mortality between developed and developing countries. As a continent, Europe is no exception. This study examines the state of activation of CC screening in the European Union as of March 2014, reviews CC incidence and mortality data, and highlights the initiatives adopted to extend program coverage to nonresponders.

METHODS

The present study is based on the most recent data available from PubMed-indexed journals, the Web sites of the health ministries of each member state, and the Web sites of national cancer observatories; failing these sources, information was sought in scientific journals published in the local language.

RESULTS

In 2003, the European Council recommended that priority be given to organized screening program activation. Nonetheless, a number of European Union member states still lack population-based organized screening programs, and few have implemented programs directed at disadvantaged populations.

CONCLUSIONS

Several investigations have demonstrated that the women at higher CC risk are unscreened and underscreened ones. Since then, several member states have made significant efforts to set up effective prevention programs by adopting international quality standards and centralizing screening organization and result evaluation. Several developed countries and some new central-eastern European member states have poorly organized prevention programs that result in poor women's health. Diagnosis of CC is emotionally traumatic, but it is highly preventable. When CC is found early, it is highly treatable and associated with long survival and good quality of life.

Beware of Kinked Frontiers: A Systematic Review of the Choice of Comparator Strategies in Cost-Effectiveness Analyses of Human Papillomavirus Testing in Cervical Screening

OBJECTIVES

To systematically review the choice of comparator strategies in cost-effectiveness analyses (CEAs) of human papillomavirus testing in cervical screening.

METHODS

The PubMed, Web of Knowledge, and Scopus databases were searched to identify eligible model-based CEAs of cervical screening programs using human papillomavirus testing. The eligible CEAs were reviewed to investigate what screening strategies were chosen for analysis and how this choice might have influenced estimates of the incremental cost-effectiveness ratio (ICER). Selected examples from the reviewed studies are presented to illustrate how the omission of relevant comparators might influence estimates of screening cost-effectiveness.

RESULTS

The search identified 30 eligible CEAs. The omission of relevant comparator strategies appears likely in 18 studies. The ICER estimates in these cases are probably lower than would be estimated had more comparators been included. Five of the 30 studies restricted relevant comparator strategies to sensitivity analyses or other subanalyses not part of the principal base-case analysis. Such exclusion of relevant strategies from the base-case analysis can result in cost-ineffective strategies being identified as cost-effective.

CONCLUSIONS

Many of the CEAs reviewed appear to include insufficient comparator strategies. In particular, they omit strategies with relatively long screening intervals. Omitting relevant comparators matters particularly if it leads to the underestimation of ICERs for strategies around the cost-effectiveness threshold because these strategies are the most policy relevant from the CEA perspective. Consequently, such CEAs may not be providing the best possible policy guidance and lead to the mistaken adoption of cost-ineffective screening strategies.

Reaching women who do not participate in the regular cervical cancer screening programme by offering self-sampling kits: a systematic review and meta-analysis of randomised trials

INTRODUCTION

Population coverage for cervical cancer screening is an important determinant explaining differences in the incidence of cervical cancer between countries. Offering devices for self-sampling has the potential to increase participation of hard-to-reach women.

METHODS

A systematic review and meta-analysis were performed to evaluate the participation after an invitation including a self-sampling device (self-sampling arm) versus an invitation to have a sample taken by a health professional (control arm), sent to under-screened women.

RESULTS

Sixteen randomised studies were found eligible. In an intention-to-treat analysis, the pooled participation in the self-sampling arm was 23.6% (95% confidence interval (CI)=20.2-27.3%), when self-sampling kits were sent by mail to all women, versus 10.3% (95% CI=6.2-15.2%) in the control arm (participation difference: 12.6% [95% CI=9.3-15.9]). When women had to opt-in to receive the self-sampling device, as used in three studies, the pooled participation was not higher in the self-sampling compared to the control arm (participation difference: 0.2% [95% CI=-4.5-4.9%]).

CONCLUSION

An increased participation was observed in the self-sampling arm compared to the control arm, if self-sampling kits were sent directly to women at their home address. However, the size of the effect varied substantially among studies. Since participation was similar in both arms when women had to opt-in, future studies are warranted to discern opt-in scenarios that are most acceptable to women.