Population-based organized cervical cancer screening pilot program in France

[Budget impact of self-testing in the national cervical cancer screening program]

OBJECTIVES

A nationwide screening program for cervical cancer (CC) was organized in 2018 as part of the 2014-2019 French cancer plan, with the objective of reducing CC incidence and mortality in France by reaching an 80 % coverage rate. As an alternative to pap smear, vaginal self-sampling (VSS) aimed at identifying high-risk HPV carriage could help to achieve this goal. The objective of the present study is to compare the respective budgetary impacts of several self-sampling strategies.

METHOD

A budget impact model was developed to compare non-use of self-sampling in CC screening to the 5-year costs of 5 VSS strategies viewed from an all-payer perspective. While the first strategy was based on mailing the VSS kit with a reminder to participate in the screening program, the second was based on accompanying the mailed kit with an invitation to participate. The third and fourth strategies were based on providing health professionals with the kit, and thereby offering self-sampling as an alternative to pap smears for women undergoing CC screening and having previously received the kits. Finally, the fifth strategy was based on self-sampling as the one and only CC screening modality. The parameters of the model were based on past screening participation data and experiments in France on organized screening and VSS use. The costs included those of procedures associated with screening and program organization.

RESULTS

All in all, the costs associated with cervical cancer screening would represent approximately 1 billion euros over 5 years. All strategies would be associated with participation ranging from 81% to 84%, which would represent an increase of 4.7% to 5.2% of lesions diagnosed by screening and a cost reduction between €30M and €87M over 5 years, with the exception of the strategy based on sending the kit (with the reminder associated or not) to the health professionals offering this option (+€23M and +€6M).

CONCLUSIONS

In conclusion, the use of self-sampling as an alternative to pap smears for non-participating women would increase participation, with only a moderate budgetary impact and could, in some cases, even induce savings.

Participation rate in cervical cancer screening in general practice related to the proximity of gynecology care facilities: A 3 year follow-up cohort study

Cervical cancer screening (CCS) by Pap tests is mainly performed by gynecologists in France, but also by general practitioners (GPs) and midwives. The screening uptake is insufficient to reduce the incidence of cervical neoplasms. Our aim was to investigate the association between screening rates in patients listed with GPs and the distance between GPs' offices and gynecology facilities. The population of 345 GPs, and their 93,918 female patients eligible for screening over 3 years (2013-2015), were derived from the Health Insurance claim database. We estimated the socioeconomic level of the geographical area of GPs' offices using the European Deprivation Index (EDI). The proximity of gynecology facilities was calculated by computing their distance from GPs' offices (in order to adjust the proximity of gynecology facilities with EDI and performance of smears by the GP). The number of gynecologists within 5 km of a GP's office was associated with the CCS rate increasing by 0.31% for every unit increase in the density of gynecologists within 5 km (p < 0.0001). The close proximity of gynecology facilities was not significantly associated with screening uptake among female patients when the office of the GP where they were registered was settled in a deprived area.

Health economic evaluation of an mRNA high-risk human papillomavirus (HR-HPV) assay versus a DNA HR-HPV assay for the proposed French cervical screening programme

OBJECTIVE

Population screening programmes must make good use of resources for the health system and users. To evaluate impacts of the type of diagnostic test in the new French cervical screening programme, an messenger ribonucleic acid (mRNA) high-risk human papillomavirus assay was compared to a deoxyribonucleic acid (DNA) high-risk human papillomavirus assay for a hypothetical cohort of women aged 25 to 65 years.

PERSPECTIVE

This evaluation takes the perspective of the French healthcare system.

SETTING

France.

METHODS

A decision tree model reflecting the French cervical screening algorithms was parametrised using French cost and population data and the Danish Horizon study. The outcomes were total costs, and number of colposcopies, HPV tests and cytology tests for the cohort. One-way and probabilistic sensitivity analyses and scenarios analyses were conducted to test the robustness of results to parameter and structural uncertainty.

RESULTS

Adopting an mRNA versus DNA assay as part of national cervical screening in France is estimated to save €6.5 million (95% credibility intervals €-1.3 - €13.5 million) and prevent 47,795 (95% credibility intervals 35,309 - 60,139) unnecessary colposcopies, 38,666 unnecessary HPV tests and 121,670 cytology tests over two years for a cohort of 2,168,806 million women aged 25 to 65 years. Sensitivity analyses indicated robust results across a range of inputs.

CONCLUSION

The choice of high-risk human papillomavirus assay makes a significant difference to resource use and costs and is important to consider when implementing cervical screening in France. Using an mRNA versus DNA assay can result in cost savings and reductions in unnecessary testing and procedures, which in turn benefits women and the health care system.

A Home-Mailed Versus General Practitioner-Delivered Vaginal Self-Sampling Kit for Cervical Cancer Screening: A Cluster Randomized Controlled Trial with a Cost-Effectiveness Analysis

Objective: We assessed whether general practitioner (GP) delivery of a vaginal self-sampling kit was non-inferior to home-mailed delivery on cervical cancer screening (CCS) participation. Methods: Two hundred and ten French GPs from Indre-et-Loire French department were randomized into two groups, and their unscreened women patients aged 30-65 were included in February-March 2015. In the GP delivery group (n = 105 GPs; 1,806 women), women were sent a reminder letter inviting them to collect a vaginal self-sampling kit at their regular GP's practice. In the home-mailed delivery group (n = 105 GPs; 1,806 women), women were sent a reminder letter with a vaginal self-sampling kit directly at home. The primary outcome was participation in complete CCS within 9 months. A cost-effectiveness analysis was also performed. Results: At 9 months, 14.9% (95% CI: 12.9-16.9) and 27.9% (95% CI: 25.7-30.0) of women in the GP and home-mailed delivery groups participated in complete CCS. The absolute between-group difference was -13.0 percentage points (95% CI: -15.9 to -10.0) in favor of the home-mailed delivery group, crossing the non-inferiority pre-defined non-inferiority margin of 5%. The home-mailed delivery strategy cost 50.81€ more per additional woman screened. Conclusions: The GP delivery was inferior to home-mailed delivery in increasing participation in CCS. Home-mailed delivery of a vaginal self-sampling kit is a cost-effective way to increase CCS in that the additional cost of this strategy seems acceptable. This study is registered at www.Clinicaltrials.gov NCT02255084.

Social Inequalities in Participation in Cervical Cancer Screening in a Metropolitan Area Implementing a Pilot Organised Screening Programme (Paris Region, France)

Objectives: We aimed to examine social inequalities in participation in cervical cancer screening (CCS) in a metropolitan area by implementing a pilot organised screening programme. The pilot programme consisted of sending invitations to women who did not perform a pap smear within the past 3 years, managing interventions to reach vulnerable women, training healthcare professionals, and organising follow-ups of abnormal pap smears. Methods: We studied participation in CCS between January 2014 and December 2016 among 241,257 women aged 25-63 years old. To assess relative inequalities, Odds Ratios were computed using multilevel logistic regression. To assess absolute inequalities, the CCS coverage and the rate difference were calculated. Inequalities were computed by age and neighbourhood characteristics (social deprivation and proportion of single women). Results: Disparities in participation in CCS were observed by age and social deprivation. For overall screening compared to opportunistic screening, disparities by age were larger (OR25-35_vs._55-64 = 2.13 [2.08-2.19] compared to 2.02 [1.96-2.07]), but disparities by social deprivation were decreased (OR10%_most_vs._10%_least_deprived = 2.09 [1.90-2.30] compared to 2.22 [2.02-2.44]). Conclusion: Disparities in CCS participation remain despite the organised programme. To reduce these inequalities, free screening should be proposed and evaluated.

Updated evidence-based recommendations for cervical cancer screening in France

INTRODUCTION

A national organized cytology-based cervical cancer screening program was launched in 2018 and rollout is ongoing. Concomitantly, the High Authority for Health (HAS) recently assessed new evidence on primary HPV testing to update screening recommendations.

METHODS

The HAS commissioned systematic reviews and meta-analyses to evaluate the effectiveness of primary HPV screening; accuracy of HPV testing on self-samples; effectiveness of self-sampling to reach underscreened women; and triage strategies to manage HPV-positive women. Recommendations developed by the HAS were reviewed by a multidisciplinary group.

RESULTS

Compared with cytology screening, HPV screening is more sensitive to detect precancers but less specific. In women aged ≥30, if the test is negative, HPV screening greatly reduces the risk of developing precancer and cancer for at least 5 years. HPV testing, using validated PCR-based assays, is as sensitive and slightly less specific on self-samples than on clinician-taken samples. Self-sampling is more effective to reach underscreened women than sending invitations to have a specimen taken by a clinician. Two-time triage strategies ensure a sufficiently high risk if triage-positive to justify referral and low risk if triage-negative allowing release to routine screening.

CONCLUSIONS

The HAS recommends three-yearly cytology screening for women aged 25-29 and HPV screening for those aged 30-65 with an extension of the screening interval to 5 years if the HPV test is negative. Self-sampling should be offered to underscreened women aged ≥30. HPV-positive women should be triaged with cytology. Those with abnormal cytology should be referred for colposcopy and those with normal cytology re-tested for HPV 12 months later. Recommendations for implementation of HPV-based screening in the organized program are provided.

Acceptability of vaginal self-sampling with high-risk human papillomavirus testing for cervical cancer screening: a French questionnaire-based study

In France, cervical cancer screening based on cervical smear has a participation rate of around 60%. New screening strategies are encouraged to increase the participation of under-screened women, including vaginal self-sampling with high-risk human papillomavirus (HR-HPV) testing. This study was based on the distribution of an anonymous self-administered questionnaire to assess the acceptability of vaginal self-sampling with HR-HPV testing by women aged 25 to 65 years in two French Departments of the South of France, Aude, and Hérault, showing low participation in cervical cancer screening. Factors influencing this acceptability were also analyzed. From May to July 2017, 349 completed questionnaires were collected. Women declared high acceptability for vaginal self-sampling (81%) preferably at home (82.6%). Acceptability was statistically higher in the Department of Herault (p = .001) and for women older than 50 years (p = .018). There was no difference according to educational level or attendance to cervical cancer screening. Knowledge about cervical cancer and cervical cancer screening was significantly influenced by educational level. This study confirmed that vaginal self-sampling with HR-HPV testing was highly accepted, including by under-screened women, encouraging further interventional studies. Education about cervical cancer and cervical cancer screening should be part of these programs, especially for women with lower educational level.

Gynaecological cancer in Caribbean women: data from the French population-based cancer registries of Martinique, Guadeloupe and French Guiana (2007-2014)

BACKGROUND

For the first time, we present regional-level cancer incidence and world-standardized mortality rates for cancers for Martinique, Guadeloupe and French Guiana.

METHODS

For Martinique, Guadeloupe and French Guiana, incidence data come from population-based cancer registries, and cover the periods 2007-2014, 2008-2014 and 2010-2014 respectively. Standardized incidence and mortality rates were calculated using the world population.

RESULTS

In the 3 regions, all cancers combined represent 3567 new cases per year, of which 39.8% occur in women, and 1517 deaths per year (43.4% in women). Guadeloupe and Martinique present similar world-standardized incidence rates. Among gynaecological cancers, breast cancer, the second most common cancer type in the 3 regions, has an incidence rate 35 to 46% lower than in mainland France. On the other hand, cervical cancer has a higher incidence rate, particularly in French Guiana. For both endometrial cancer and ovarian cancer, no significant differences in incidence rates are found compared to mainland France. Regarding mortality, world-standardized mortality rates are similar between Guadeloupe and Martinique, and higher than in French Guiana. This situation compares favourably with mainland France (all cancers). Among gynaecological cancers, the mortality rate is lower for breast cancer in all regions compared to mainland France, and also lower for ovarian cancer in Martinique and Guadeloupe, but higher (albeit non-significantly) in French Guiana.

CONCLUSION

The ethno-geographic and socio-demographic characteristics in this population of mainly Afro-Caribbean origin could partially explain these disparities. Major disparities exist for certain cancer sites: excess incidence and excess mortality for cervical cancer; lower, but increasing incidence of breast cancer.

HPV-vaccination and cancer cervical screening in 53 WHO European Countries: An update on prevention programs according to income level

Human papillomavirus (HPV) is the most common sexually transmitted disease in the world. The aim of our study is to describe the differences in HPV‐vaccination coverage and screening programs in WHO European Countries notably according to income levels. Multiple correspondence analysis was applied to examine the association among the following variables: Gross National Income (GNI) levels (Lower‐Middle Income, LMI; Upper‐Middle Income, UMI; and High Income, HI); type of CC screening program (coverage; opportunistic/organized); vaccination payment policies (free or partial or total charge); mortality rates/100 000 (≤3; >3‐6; >6‐9; >9); incidence rates/100 000 (≤7; >7‐15; >15‐21; >21). Data HPV‐vaccination start (years) (2006‐2008; 2009‐2011; 2012‐2014; >2014; no program); coverage HPV‐vaccination percentage (≤25; 26‐50; 51‐75; >75); data screening start (years) (<1960; 1960‐1980; 1981‐2000; >2000); primary screening test (HPV, cytology), and screening coverage percentage (≤25; >25‐50; >50‐75; >75). A high income is associated with: start of screening before 1960, medium‐high screening coverage, organized screening, start of vaccination in the periods 2009‐2011 and 2012‐2014 and high immunization coverage. On the other hand, lower‐middle income is associated with: late start of vaccination and screening programs with cytology as primary test, high mortality and incidence rates and lower‐medium vaccination coverage. Our results show a useful scenario for crucial support to public health decision‐makers. Public health authorities should monitor the HPV‐vaccinated population in order to determine more precisely the effects on short‐ and long‐term incidence and mortality rates. In fact, the greater the vaccination coverage, the greater will be the efficacy of the program for the prevention of CC and other HPV‐related diseases.

[Implementation of National Cervical Cancer Screening Program in France]

In 2017 in France, cervical cancer (CC) was diagnosed in 2850 women and 1100 women died. The decline in incidence and mortality rates observed for several decades has slowed since the early 2000s. CC is due to the persistence of a sexually transmitted infection by human papillomaviruses (HPV). Currently CC prevention depends on HPV vaccination and Pap smear tests (PST) and up until 2018 diagnosis has been carried out an individual basis in France. The 2014-2019 French Cancer Plan has planned to implement a nationally organized screening program of CC which proposes in the short term to continue screening by PST, according to the recommendations set by HAS in 2010, while creating the conditions for the transition to HPV-testing in primary screening. The objective of this program is to reduce the incidence and number of CC deaths by 30% within the next 10 years, by achieving an 80% coverage rate in the target population and making screening more accessible to vulnerable populations and/or those who have poor access to the healthcare system. CC is one of the rare cancers that could become exceptional. The combination of the two primary and secondary prevention methods, with high rates of vaccination and screening coverage, should make it possible to eliminate this cancer in countries with sufficient economic resources for the effective implementation of these prevention programs.

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.

Towards equity in organised cancer screening: the case of cervical cancer screening in France

BACKGROUND

The French national cancer institute (INCa) conducted a series of studies to assist decision-making in view of the implementation of organised cervical cancer screening that will be launched in 2018. The programme will concern all women aged 25-65 and targeted interventions will be developed for underscreened populations. This is an evolution from an equality-based approach to a step-by-step strategy of equity aiming to tackle health cancer inequalities that are avoidable and represents unfair differences. Here we present the work of the expert-group in ethics drafted by INCa to review the ethical issues prior to the programme implementation.

DISCUSSION

We discuss the value of such a strategy and presents reflections with regard to issues of stigmatization, respect for individual freedom and autonomy. Indeed, the balance has to be found between the search for beneficence and the potential occurrence of perverse effects, which should be considered with particular attention.

CONCLUSION

Moving toward an equity-oriented policy under a strategy of proportionate universalism faces a number of challenges, thus an overview of ethics and social sciences must be an integral part of the process.

Organised screening for cervical cancer in France: a cost-effectiveness assessment

OBJECTIVE

According to the third cancer plan, organised screening (OS) of cervical cancer (CC) among women aged 25-65 years should be implemented in France in the forthcoming years. The most efficient way to implement OS in the French healthcare system is yet to be determined.

METHODS

A microsimulation model was developed adopting a collective 'all payers' perspective. A closed cohort of women eligible for CC screening and representative in terms of age and participation in individual screening (IndScr) by annual Papanicolaou (Pap) testing every 3 years was modelled on a lifetime horizon. Different OS strategies, additive to IndScr with a 61.9% participation rate based on mailed invitations to non-participant women to perform OS were assessed. Similar modalities were applied to OS and IndScr participants. Strategies implied different screening tests (Papanicolaou (Pap) test, human papillomavirus (HPV) test and p16/Ki67 double staining) and OS periodicity.

RESULTS

Compared with IndScr only, all OS strategies were associated with decreased cancer incidence/mortality (from 14.2%/13.5% to 22.9%/25.8%). Most strategies generated extra costs ranging from €37.9 to €1607 per eligible woman. HPV testing every 10 and 5 years were cost saving. HPV tests every 10 and 5 years were the most efficient strategies, generating more survival at lower costs than Pap-based strategies. Compared to IndScr only, an HPV test every 10 years was cost saving. The most effective strategies were p16/Ki67 as primary or HPV positive confirmation tests, with respective incremental cost-effectiveness ratios of €6 541 250 and €101 391 per life year. Pap-based strategies generated intermediary results.

CONCLUSION

OS strategies based on the HPV test appear highly efficient. However, our results rely on the assumption that women and practitioners comply with the recommended OS periodicities (3, 5, 10 years). Implementing these OS modalities will require major adaptations to the current CC screening organisation. Pap test-based strategies might be simpler to setup while preparing an appropriate implementation of more efficient OS screening modalities.