Impact of organized and opportunistic Pap testing on the risk of cervical cancer in young women - A case-control study from Finland

Cervical cancer screening and outcomes for women under 25 years of age in Belgium: a 10-year nationwide study

OBJECTIVE

The aim of the study was to describe trends in cervical cancer screening and outcomes for women under 25 years of age in Belgium between 2010 and 2019 in response to a changed reimbursement policy.

MATERIALS AND METHODS

We used the databases of the National Health Insurance Institute (RIZIV/INAMI) and the Belgian Cancer Registry (BCR) for a nationwide description of cervical screening, subsequent diagnostic procedures and outcomes for women younger than 20 years and women aged 20-25 years between 2010 and 2019.

RESULTS

Over a 10-year period, the number of cytology screening tests and annual screening rates in women younger than 25 years have been reduced by 50%, but no increases in invasive cervical cancer or high-grade intraepithelial lesion diagnoses were observed. The major determinant of this decreased overscreening has been the limitation of reimbursement in 2013 to once every 3 years instead of once every 2 years. In women aged 25-29 years, there is no increase in invasive cervical cancer diagnoses after decreased screening of women younger than 25 years. To detect 29 invasive cervical cancers in women younger than 25 during the 10-year study period, a total of 5606 conizations were performed and 43 million EUR of Belgian health insurance budget was spent. Since the cost of hospitalization, sickness leave and negative psychological impact were not included in our estimation, these costs are underestimated.

CONCLUSION

Incidence of cervical cancer in women under 25 years remains low and screening is not effective in preventing cervical cancer, although there is clear evidence of potential reproductive harm and financial cost. We state that restricting reimbursement of cervical cancer screening before the age of 25 will improve guideline adherence and decrease healthcare expenditures without negatively impacting the health of the population.

Effectiveness of Cervical Testing in and outside a Screening Program-A Case-Control Study

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.

Cervical cancer screening patterns among HIV-positive women in Estonia: a population-based retrospective cohort study

BACKGROUND

The World Health Organisation (WHO) calls for the elimination of cervical cancer (CC) as a public health issue. To achieve elimination, efforts must be aligned and accelerated. Women living with HIV (WLWH) have excess risk for developing, and dying from, CC over the general population. Estimates of cervical cancer screening programme coverage in Eastern European countries that have experienced HIV epidemics since the early 2000's are scarce.

METHOD

This population-based retrospective study uses a healthcare administrative database and follows cohorts of all WLWH in a ratio of 1:3 randomly matched (age, region) HIV negative women from 2009 to 2018. Annual and longitudinal (over the whole study period) coverage for cervical cancer screening (opportunistic, organised, HIV specific) and adjusted odds ratios (AORs) for longitudinal screening coverage predictors were estimated from 2009 to 2018.

RESULTS

Among WLWH and HIV-negative women, the mean annual coverage with opportunistic screening was 61.45 and 65.59%; and organised screening was 20.4 and 28.7%, respectively (both: p < 0.00001). 19.01% (95% CI 18.05-19.97) HIV-negative and 13.9% (95% CI 12.35-15.45) WLWH were longitudinally covered with organised cervical cancer screening. Among WLWH, the mean annual HIV-specific cervical cancer screening coverage was 49.4, and 24.3% were longitudinally covered. Longitudinal coverage with HIV-specific cervical cancer screening was inversely associated with age, hepatitis C virus (HCV) co-infection (AOR 0.754, 95% CI 0.619, 0.916), not having insurance (AOR 0.331, 95% CI 0.264, 0.412), drug abuse (AOR 0.459, 95% CI 0.336, 0.618) and higher among those retained in HIV care (AOR 1.972, 95% CI 1.615, 2.410). Among HIV-negative women, longitudinal coverage with organised cervical cancer screening was inversely associated with residence in the region and higher among older women.

CONCLUSIONS

Our results highlight unacceptably low coverage of cervical cancer screening of WLWH in Estonia. There is need for dedicated cervical cancer screening efforts for WLWH considering the high cancer risk and rate in the study population.

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

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

Effectiveness of the cervical cancer prevention programme: a case-control mortality audit in Lithuania

The cervical cancer burden in Lithuania has remained high, and there are no previous effectiveness studies of cervical cancer prevention programme in the country. We investigated the effect of a prevention programme on the risk of mortality from cervical cancer in Lithuania by conducting a mortality audit study. The register-based case-control study included 715 cervical cancer deaths that occurred during 2010-2015 in Lithuania and their 2145 matched controls. Screening histories for cases and controls were obtained from the National Health Insurance Fund database. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression and corrected for self-selection bias. Index screening was associated with a 56% reduction in the cervical cancer death risk, OR: 0.44; 95% CI 0.26-0.74. The ORs for stage I and stage II+ cancers were 0.80; 95% CI 0.32-2.00 and 0.36; 95% CI 0.21-0.62, respectively. The preventive effect was statistically significant for women aged ≥40 years, while nonsignificant for younger. In women who died of cervical cancer, 71% were not invited and 88% were not screened within the recommended 36 months prior to index date. Among cases with index invitation, 32% had index screening compared to 70% in controls. In conclusion, participation in screening has been effective in reducing cervical cancer mortality in Lithuania. The study shows poor screening attendance, emphasizing the importance of greater efforts at the national level to improve the effectiveness of the screening.

The effect of age On cervical cancer screening in women aged 20-29

No definite consensus exists currently regarding the appropriate age at which to start cervical cancer screening. We analyzed the effectiveness of age in abnormal histology outcomes in women aged 20-29. Data on women aged 20-29 having undergone opportunistic cervical cancer screening with cytology during the 2014-2019 period were retrospectively reviewed. Based on cytology outcomes, human papillomavirus test results (if present), age and clinical decision, patients underwent either colposcopy or observation. The effects of age and other epidemiologic factors on histologic diagnoses of cervical intraepithelial neoplasia (CIN) or cancer [CIN (+)] were analyzed in univariate and binomial logistic regression analyses. Among 1649 women, CIN (+) lesions were observed in 61 (3.7%) women. The occurrence of CIN (+) lesions increased 1.149 times each year; thus, women aged 25-29 were more likely to have CIN (+) than those aged 20-24 (4.4% vs. 2.1%; p=0.019). A significant determinant of CIN (+) was the increase in age, i.e. women aged 20-29. Accordingly, considering age is crucial for the diagnosis of CIN (+) in cancer screening.

Recent increase in incidence of cervical precancerous lesions in Norway: Nationwide study from 1992 to 2016

We analysed patterns in the incidence of cervical intraepithelial neoplasia grades 2 and 3 (CIN2, CIN3) and adenocarcinoma in situ (AIS) by age and histology in 1992–2016 in Norway and described changes in screening tests. Incident cases of CIN2, CIN3, AIS and cervical cancer were identified in the Cancer Registry of Norway, as were all women with at least one screening test. The annual percentage change statistic was used to assess point estimates and changes in age‐specific and age‐standardised incidence rates (IR). Women aged 25–29 years had the highest incidence of cervical precancerous lesions (CIN2: 192.9/10, CIN3: 737.2/10, AIS: 32.5/10⁵ in 2016). The IR of CIN2 increased for all screening ages (25–69 years) from 3.6% to 6.7% per year. CIN3 incidence increased by 1.6% (95% confidence interval [CI] 0.6–2.6) annually. A steep increase in AIS incidence was observed in all age groups (7.1% per year, 95% CI 5.3–8.8). Changes in screening tests and the histological verification of cervical precancerous lesions alone cannot explain the steady increase in incidence we observed over the 25‐year study period, and increased exposure to human papillomavirus (HPV) likely plays a role. Age‐appropriate treatment of screening‐detected cervical precancerous lesions is needed for effective cervical cancer control while avoiding overtreatment and related health risks. In order to perform an appropriate harm‐benefit evaluation of cervical cancer control efforts, detailed information on screening technology and background risks, including HPV vaccination status, is needed to create optimal public health policy.

What's new?

In Norway, cervical cancer screening coverage has held steady around 65–68%, while incidence of cervical precancerous lesions has increased. Here, the authors analysed changes in incidence of cervical intraepithelial neoplasias grades 2 and 3 (CIN2 and 3) and adenocarcinoma in situ (AIS). They observed period effects of the same magnitude for all three, indicating that changes in the screening test accounts for part of the increase. Another likely cause, they report, is increased exposure to HPV. Public health policy, they conclude, should consider detailed information on screening technology and background risks, including HPV vaccination status.

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.

Reducing overuse of cervical cancer screening: A systematic review

Overuse of clinical preventive services increases healthcare costs and may deprive underserved patients of necessary care. Up to 45% of cervical cancer screening is overuse. We conducted a systematic review of correlates of overuse of cervical cancer screening and interventions to reduce overuse. The search identified 25 studies (20 observational; 5 intervention). Correlates varied by the type of overuse measured (i.e., too frequent, before/after recommended age to start or stop screening, after hysterectomy), the most common correlates of overuse related to patient age (n = 7), OBGYN practice or provider (n = 5), location (n = 4), and marital status (n = 4). Six observational studies reported a decrease in overuse over time. Screening overuse decreased in all intervention studies, which used before-after designs with no control or comparison groups. Observational studies suggest potential targets for de-escalating overuse. Randomized clinical trials are needed to establish best practices for reducing overuse.