Adolescent characteristics and incidence of pre-malignant disease and invasive tumors of the cervix

INTRODUCTION

Pre-malignant cervical disease and invasive cervical cancer present a significant global health burden with respect to morbidity and mortality, mostly in low- and middle-income countries. Human papillomavirus (HPV) infection typically manifests for the first time in adolescence. We aimed to identify adolescent sociodemographic and anthropometric characteristics associated with subsequent risk for pre-malignant cervical disease and cervical cancer, in a country that offers free screening and HPV vaccines.

METHODS

This historical cohort study included 969 123 Israeli women examined and anthropometrically measured at age 17 years between January 1967 and December 2011. Data on pre-malignant disease and invasive cervical tumors were obtained from the national cancer registry by linkage. We excluded non-Jewish minorities (a total of 25 472 women) and orthodox/ultraorthodox Jewish women since these populations are not required by law to serve in the military, as well as women with a pre-examination diagnosis of cancer. Cox proportional hazards regression models were applied per each lesion type, adjusted for origin, measured body mass index, height, education, dwelling type, birth year, and age at examination.

RESULTS

In total, 5094 and 859 incident pre-malignant cervical disease and cervical cancer cases, respectively, were diagnosed during a median follow-up of 17.6 years. Risk for both lesions was origin-dependent, with higher incidence in women of North-African origin (HR (pre-malignant cervical disease) 1.22, 95% CI 1.04 to 1.42; HR (cervical cancer) 1.87, 95% CI 1.30 to 2.69) compared with European origin. Height, lower education, and later birth year were associated with higher pre-malignant cervical disease and cervical cancer risk also. Adolescent overweight (HR 0.81, 95% CI 0.74 to 0.90) and obesity (HR 0.56, 95% CI 0.43 to 0.71) status were associated with reduced pre-malignant cervical disease but not cervical cancer incidence, as did urban (vs rural) residence.

DISCUSSION

Ethnic background, tall stature, and education were associated with pre-malignant cervical disease and cervical cancer incidence, while adolescent overweight and obesity were inversely associated with only pre-malignant cervical disease. Despite free screening and HPV vaccines, these findings suggest that there is still a need for appropriate safe sex and screening education in adolescence.

Recent trends of cervical cancer and Cervical Intraepithelial Neoplasia 3 (CIN3) in Israel

PURPOSE

This study describes time trends of cervical cancer and Cervical Intraepithelial Neoplasia 3 (CIN3) in Israel in the years 1986-2010 and characterizes these patients by demographics.

METHODS

A retrospective survey based on cervical cancer and CIN3 data documented in the computerized system of the second largest Health Maintenance Organizations (HMO) in Israel, "Maccabi Healthcare Services" (MHS) between 1986 and 2010.

RESULTS

737 cervical cancer patients and 3,459 patients of CIN3 were reported between 1986 and 2010. The mean age of women with cervical cancer was significantly higher (mean 49.1 years) than that of CIN3 patients (mean 36.3 years) (p-value < 0.0001). The annual age-adjusted incidence rate of cervical cancer increased significantly from 1.6 per 100,000 in 1986 to 3.7 per 100,000 in 2010 (p for trend = 0.0001) and for CIN3, from 3.9 per 100,000 in 1986 to 40.4 per 100,000 in 2010 (p for trend = 0.0001). For cervical cancer, using the Joinpoint software we demonstrated an increase in the age-adjusted incidence rate between 1986 and 2003 and since then, a decrease was observed. Cervical cancer and CIN3 were mostly common in the Tel Aviv District.

CONCLUSIONS

Although quite low to begin with, the incidence rates of cervical cancer and CIN3 in Israel may be further lowered by implementing an organized screening program and introduction of the HPV vaccine into the national immunization program.

Burden of human papillomavirus infection and related diseases in Israel

This manuscript provides the available data on the burden of human papillomavirus (HPV) infections and HPV-related diseases in Israel. The incidence of cervical intraepithelial neoplasia grade 3 (CIN3) among Jewish women was 17.4 per 100,000 in 2007, showing an increase since 1997. The incidence of cervical cancer was 5.3 per 100,000 Israeli Jewish women and 2.3 per 100,000 Israeli non-Jewish women in 2007. This rate is relatively low compared to other developed countries, and could be explained by cultural and religious factors such as male circumcision or sexual behavior. Mortality rates were around 1.5 per 100,000 Israeli women in 2007. Incidences of other anogenital, oral cavity, and pharynx cancers are very low, below 1.0 per 100.000 Israeli women and men. Information is scarce on HPV prevalence and HPV type distribution among women with cervical cancer. HPV types 16 and 18 were the two most common types in both preneoplastic lesions and cervical cancer, representing 60% of total invasive cases. Data on genital warts show an incidence rate of 239 per 100,000 men and 185 per 100,000 women, similar to that found in other Western countries. Despite these low incidences, it is important to improve the information on the overall burden of HPV-related morbidity and on the HPV prevalence to evaluate an organized cervical cancer screening program and the introduction of the HPV vaccine in the national school-based vaccine program. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in Israel" Vaccine Volume 31, Supplement 8, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Uptake of Pap smears among women in a large Israeli HMO between 2006 and 2008

OBJECTIVES

The Papanicolaou (Pap) smear test is used in many countries as a screening procedure for cervical cancer and precancerous lesions. The actual uptake of this screening test among women at risk for cervical cancer is unknown. The aim of this study was to estimate the percentage of women who are screened by Pap smears from the relevant population at risk, and to detect factors that are independently associated with uptake of cervical screening.

STUDY DESIGN

Retrospective database study.

METHODS

This study was undertaken at Maccabi Healthcare Services (MHS), the second largest publicly funded health maintenance organization in Israel. The study population consisted of Israeli women aged 21-59 years who were insured by MHS between 2006 and 2008. Logistic regression analyses were used to determine the independent relationships between immigration and socio-economic status and cervical screening.

RESULTS

The study population included 489,663 women who had a total of 313,602 Pap smears between 2006 and 2008. Fifty-four percent of the women did not have a Pap smear during the study period, 32% had at least one smear, and 14% had at least two smears. Living in a low socio-economic neighbourhood and recent immigration were independently and negatively associated with screening uptake.

CONCLUSION

Despite the clinical guidelines and the low costs, many Israeli women who are at risk for cervical cancer are not screened.

Morbidity and mortality in gynecological cancers among first- and second-generation immigrants in Sweden

We studied the effect of new environment on the risk in and mortality of gynecological cancers in first- and second-generation immigrants in Sweden. We used the nationwide Swedish Family-Cancer Database to calculate standardized incidence/mortality ratios (SIRs/SMRs) of cervical, endometrial and ovarian cancers among immigrants in comparison to the native Swedes. Risk of cervical cancer increased among first-generation immigrants with Danish (SIR = 1.64), Norwegian (1.33), former Yugoslavian (1.21) and East European (1.35) origins, whereas this risk decreased among Finns (0.88) and Asians (SIRs varies from 0.11 in Iranians to 0.54 in East Asians). Risk of endometrial (SIRs varies from 0.28 in Africans to 0.86 in Finns) and ovarian (SIRs varies from 0.23 in Chileans to 0.82 in Finns) cancers decreased in first-generation immigrants. The overall gynecological cancer risk for the second-generation immigrants, independent of the birth region, was almost similar to that obtained for the first generations. The birth region-specific SMRs of gynecological cancers in first- and second-generation immigrants co-varied with the SIRs. Risk of gynecological cancers among the first-generation immigrants is similar to that in their original countries, except for cervical cancer among Africans and endometrial cancer among North Americans and East Europeans. Our findings show that risk and mortality of gynecological cancers observed in the first-generation immigrants remain in the second generation. We conclude that the risk and protective factors of gynecological cancers are preserved upon immigration and through generations, suggesting a role for behavioral factors or familial aggregation in the etiology of these diseases.