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

Educational inequalities in cervical cancer screening participation in 24 European countries

OBJECTIVES

Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation.

RESULTS

Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75).

CONCLUSION

Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

The impact of the CervicalCheck controversy on provision of colposcopy services in Ireland: A cohort study

OBJECTIVES

In 2018, an inquiry into the Irish Cervical Cancer screening programme (CervicalCheck) was initiated, following publicised cases of non-disclosure regarding internal audit results of cytology screening in women diagnosed with cervical cancer. The inquiry attracted widespread media coverage and the government offered women free, out of programme screening. We investigated whether the controversy led to an increase in referrals based on clinical suspicion and the impact on waiting times for abnormal cytology.

STUDY DESIGN

A retrospective cross-sectional analysis was performed, including all colposcopy referrals to The National Maternity Hospital, Dublin, before (March 2016-2018) and after (March 2018-2020) the media coverage. Chi-squared (χ2) and independent one-tailed t-tests were used to perform between-group analyses.

RESULTS

Post-controversy, suspicious cervix referrals increased (10.1 %-14.2 %; p = 0.037 × 10^-27), as did colposcopic impression of CIN (p = 0.000000016). While an increase in CIN1 histology (18.5 %-30.3 %) was diagnosed, a decrease in high-risk CIN2 (10 % to 8.6 %), CIN3 (6.2 % to 2.9 %), AIS (1.2 % to 0.3 %) and invasive cancer (2.8 % to 1.2 %; p = 0.0058 × 10^-9) were diagnosed. Across all grades of cytological abnormality, significantly fewer patients were reviewed in the recommended waiting time post-controversy. Half of delayed abnormal cytology referrals had high-grade changes.

CONCLUSIONS

This study highlights the profound impact that the CervicalCheck Controversy had on the women attending colposcopy and clinicians performing the screening tests, and the direct impact on women with confirmed cytological abnormalities. The increase in suspicious cervix referrals reflects a lack of confidence in both clinical practice and screening test results. The importance of public trust in the effective delivery of screening services cannot be ignored. Increased resources are required to ensure all women are seen within recommended time frames. Heightened anxiety and increased surveillance does not necessarily lead to better clinical outcomes for patients but can result in unnecessary distress for low-risk patients and delays to diagnosis for high-risk patients with concerning abnormalities.

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.

Organized screening programmes for breast and cervical cancer in 17 EU countries: trajectories of attendance rates

BACKGROUND

The aim was to analyse participation trajectories in organised breast and cervical cancer screening programmes and the association between socioeconomic variables and participation.

METHODS

A pooled, cross-sectional, time series analysis was used to evaluate secondary data from 17 European countries in 2004-2014.

RESULTS

The results show that the mammographic screening trend decreases after an initial increase (coefficient for the linear term = 0.40; p = 0.210; 95% CI = - 0.25, 1.06; coefficient for the quadratic term = - 0.07; p = 0.027; 95% CI = - 0.14, - 0.01), while the cervical screening trend is essentially stable (coefficient for the linear term = 0.39, p = 0.312, 95% CI = - 0.42, 1.20; coefficient for the quadratic term = 0.02, p = 0.689, 95% CI = - 0.07, 0.10). There is a significant difference among the country-specific slopes for breast and cervical cancer screening (SD = 16.7, p < 0.001; SD = 14.4, p < 0.001, respectively). No association is found between participation rate and educational level, income, type of employment, unemployment and preventive expenditure. However, participation in cervical cancer screening is significantly associated with a higher proportion of younger women (≤ 49 years) and a higher Gini index (that is, higher income inequality).

CONCLUSIONS

In conclusion three messages: organized cancer screening programmes may reduce the socioeconomic inequalities in younger people's use of preventive services over time; socioeconomic variables are not related to participation rates; these rates do not reach a level of stability in several countries. Therefore, without effective recruitment strategies and tailored organizations, screening participation may not achieve additional gains.