Reasons women do not attend screening for cervical cancer: a population-based study in Sweden

Strategies to Increase Cervical Cancer Screening With Mailed Human Papillomavirus Self-Sampling Kits: A Randomized Clinical Trial

Importance

Optimal strategies for increasing cervical cancer screening may differ by patient screening history and health care setting. Mailing human papillomavirus (HPV) self-sampling kits to individuals who are overdue for screening increases adherence; however, offering self-sampling kits to screening-adherent individuals has not been evaluated in the US.

Objective

To evaluate the effectiveness of direct-mail and opt-in approaches for offering HPV self-sampling kits to individuals by cervical cancer screening history (screening-adherent and currently due, overdue, or unknown).

Design, Setting, and Participants

Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Individuals aged 30 to 64 years with female sex, a primary care clinician, and no hysterectomy were identified through electronic health records (EHRs) and enrolled between November 20, 2020, and January 28, 2022, with follow-up through July 29, 2022.

Interventions

Individuals stratified as due (eg, at the time of randomization, these individuals have been previously screened and are due for their next screening in ≤3 months) were randomized to receive usual care (patient reminders and clinician EHR alerts [n = 3671]), education (usual care plus educational materials about screening [n = 3960]), direct mail (usual care plus educational materials and a mailed self-sampling kit [n = 1482]), or to opt in (usual care plus educational materials and the option to request a kit [n = 3956]). Individuals who were overdue for screening were randomized to receive usual care (n = 5488), education (n = 1408), or direct mail (n = 1415). Individuals with unknown history for screening were randomized to receive usual care (n = 2983), education (n = 3486), or to opt in (n = 3506).

Main Outcomes and Measures

The primary outcome was screening completion within 6 months. Primary analyses compared direct-mail or opt-in participants with individuals randomized to the education group.

Results

The intention-to-treat analyses included 31 355 randomized individuals (mean [SD] age, 45.9 [10.4] years). Among those who were due for screening, compared with receiving education alone (1885 [47.6%]), screening completion was 14.1% (95% CI, 11.2%-16.9%) higher in the direct-mail group (914 [61.7%]) and 3.5% (95% CI, 1.2%-5.7%) higher in the opt-in group (2020 [51.1%]). Among individuals who were overdue, screening completion was 16.9% (95% CI, 13.8%-20.0%) higher in the direct-mail group (505 [35.7%]) compared with education alone (264 [18.8%]). Among those with unknown history, screening was 2.2% (95% CI, 0.5%-3.9%) higher in the opt-in group (634 [18.1%]) compared with education alone (555 [15.9%]).

Conclusions and Relevance

Within a US health care system, direct-mail self-sampling increased cervical cancer screening by more than 14% in individuals who were due or overdue for cervical cancer screening. The opt-in approach minimally increased screening. To increase screening adherence, systems implementing HPV self-sampling should prioritize direct-mail outreach for individuals who are due or overdue for screening. For individuals with unknown screening history, testing alternative outreach approaches and additional efforts to document screening history are warranted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04679675.

Participation in screening for breast and cervical cancer among women with current or previous drug use: a survey study

BACKGROUND

Women with current or previous drug use (WCPDU) have an increased risk of poor breast and cervical cancer outcomes. Screening is known to decrease the mortality of these common cancer forms, but screening participation has been sparsely investigated among women with drug dependency. The aim of this study was to assess participation in screening for breast and cervical cancer among WCPDU.

METHODS

We recruited WCPDU to a survey study, from six opioid substitution treatment (OST) clinics and one needle exchange program (NEP) in Malmö, Sweden, and through the Drug Users Union in Stockholm, Sweden. The survey was constructed according to results from focus group discussions about cancer screening in a sample of women in OST. Survey data were analyzed using descriptive statistics. We analyzed associations between non-compliance to screening and healthcare contact (OST, NEP or none) by logistic regression analysis; unadjusted and adjusted for age, native language, housing situation, educational attainment and main source of income.

RESULTS

A total of 298 women (median age 43 years) responded to the survey. The self-reported compliance with cancer screening recommendations was 29% for breast cancer screening and 41% for cervical cancer screening. Non-compliance with cervical cancer screening was associated with NEP participation in univariate but not multivariate analysis. We did not find an association between non-compliance with breast cancer screening and healthcare contact. Non-compliance with screening for cervical cancer was also associated with unstable housing in univariate and multivariate analyses, and inversely associated with increasing age in a univariate analysis. Non-compliance with breast cancer was associated with unstable housing in a univariate analysis, and inversely associated with not having Swedish as a native language in a multivariate analysis.

CONCLUSION

The self-reported compliance with the national cancer screening programs for breast cancer and cervical cancer of WCPDU is notably lower than in the Swedish general population. Women with unstable housing seem to be particularly vulnerable to non-compliance with cancer screening. Interventions to minimize barriers to cancer screening are crucial to decrease the increased cancer morbidity and mortality among WCPDU.

Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials

Objectives

A meta-analysis was conducted to examine the effectiveness of HPV self-sampling proposal on cervical cancer screening (CCS) uptake when compared with an invitation to have a clinician to collect the sample. Secondary outcomes were acceptability and preference of self-sampling compared to clinician-collected samples.

Methods

The present systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining the CCS uptake comparing self-sampling over invitation to be sampled by an healthcare professional and examining the proportion of women accepting or preferring self-sampling vs. clinician-collected sampling were included. The CCS uptake was also explored according to strategy of self-samplers' distribution, collection device type and screening status. Peters' test and Funnel Plot inspection were used to assess the publication bias. Quality of the studies was assessed through Cochrane Risk of Bias and NIH Quality Assessment tools.

Results

One hundred fifty-four studies were globally identified, and 482,271 women were involved. Self-sampling procedures nearly doubled the probability (RR: 1.8; 95% CI: 1.7-2.0) of CCS uptake when compared with clinician-collected samples. The opt-out (RR: 2.1; 95% CI: 1.9-2.4) and the door-to-door (RR: 1.8; 95% CI: 1.6-2.0) did not statistically significant differ (p = 1.177) in improving the CCS uptake. A higher relative uptake was shown for brushes (RR: 1.6; 95% CI: 1.5-1.7) and swabs (RR: 2.5; 95% CI: 1.9-3.1) over clinician-collected samples. A high between-studies variability in characteristics of sampled women was shown. In all meta-analyses the level of heterogeneity was consistently high (I 2 > 95%). Publication bias was unlikely.

Conclusions

Self-sampling has the potential to increase participation of under-screened women in the CCS, in addition to the standard invitation to have a clinician to collect the sample. For small communities door-to-door distribution could be preferred to distribute the self-sampler while; for large communities opt-out strategies should be preferred over opt-in. Since no significant difference in acceptability and preference of device type was demonstrated among women, and swabs and brushes exhibited a potential stronger effect in improving CCS, these devices could be adopted.

Effect of Patient Characteristics on Uptake of Screening Using a Mailed Human Papillomavirus Self-sampling Kit: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Mailing human papillomavirus (HPV) self-sampling kits increases cervical cancer screening participation, but effects may differ across subpopulations. Subpopulation data can inform US health care system implementation.

OBJECTIVE

To identify patient characteristics that modify effectiveness of a mailed kit intervention at increasing screening.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of data from the Home-Based Options to Make Cervical Cancer Screening Easy (HOME) randomized clinical trial conducted from 2014 to 2018 at Kaiser Permanente Washington. Data analysis was performed from March 2018 to May 2022. Individuals aged 30 to 64 years with female sex, health plan enrollment longer than 3 years and 5 months, a current primary care clinician, and no Papanicolaou test within the prior 3 years and 5 months were identified through electronic medical records and randomized (1:1) to the control or intervention group.

INTERVENTIONS

The control group received usual care Papanicolaou screening reminders and outreach. The intervention group received usual care plus an unsolicited mailed HPV self-sampling kit.

MAIN OUTCOMES AND MEASURES

Screening uptake was captured within 6 months after randomization. Baseline patient characteristics (age, race, ethnicity, travel time to clinic, income, body mass index, tobacco use, health plan enrollment duration, time since last Papanicolaou test, mammography, comorbidities, and colorectal cancer screening adherence) were extracted from the electronic medical record.

RESULTS

Of 19 734 individuals (mean [SD] age, 50.1 [9.5] years; 14 129 [71.6%] White), 9843 were randomized to the intervention group, and 9891 were randomized to the control group. Screening uptake was 26.3% (2592 of 9843 individuals) in the intervention group vs 17.4% (1719 of 9891 individuals) in the control group (relative risk [RR], 1.51; 95% CI, 1.43-1.60). Although absolute differences in uptake by group varied little by screening history, relative effects were greater with longer vs shorter time since last Papanicolaou test (no prior Papanicolaou test: RRs, 1.85-3.25; ≥10 years: RR, 2.78; 5-10 years: RRs, 1.69-1.86; <5 years: RRs 1.29-1.37). Relative effects were greater in participants overdue (RR, 2.03; 95% CI, 1.73-2.38) vs up-to-date with mammography (RR, 1.53; 95% CI, 1.41-1.67), although absolute difference was greater in the up-to-date group. Differences by age were not significant, with RRs of 1.33 to 1.48 across 5-year age groups in participants 30 to 54, vs 1.60 (95% CI, 1.40-1.82) in participants 55 to 59 and 1.77 (95% CI, 1.56-2.01) in participants 60 to 64 years. Among those mailed kits, there were differences in kit use vs in-clinic screening by age, race, plan enrollment duration, underscreening duration, and colorectal cancer screening adherence.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, clinically important improvements in screening uptake were observed for all subgroups. Differences in magnitude of intervention effect and kit use highlighted opportunities to optimize HPV self-sampling for priority groups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02005510.

Design of a pragmatic randomized controlled trial of home-based human papillomavirus (HPV) self-sampling for increasing cervical cancer screening uptake in a U.S. healthcare system: The STEP trial

BACKGROUND

Mailing HPV self-sampling kits to overdue individuals increases cervical cancer screening adherence; offering self-sampling to previously adherent individuals has not been evaluated in the U.S. Given heterogeneity of the U.S. health system and population, data are needed to optimize how HPV self-sampling is offered to individuals who are overdue, due after successful past screening, or have an unknown screening history.

METHODS

STEP is a pragmatic randomized controlled trial set within a U.S. integrated healthcare delivery system, designed to compare different outreach approaches for offering HPV self-sampling in populations defined by prior screening behavior (previously-adherent, overdue, or unknown screening history). Over 14 months, eligible individuals were identified through electronic medical record (EMR) data and randomized to Usual Care (UC), Education (UC + educational materials about cervical cancer screening), Direct-Mail (UC + Education + a mailed self-sampling kit) or Opt-In (UC + Education + option to request a kit), depending on screening history. The primary objective is to compare screening completion by outreach approach and screening history. Secondary objectives include evaluating incremental cost-effectiveness of outreach approaches, and identifying patient preference for, and satisfaction with, HPV self-screening, and barriers to abnormal results follow-up (measured through interviews and focus groups).

CONCLUSIONS

The trial was designed to generate data that U.S. health systems can use to inform primary HPV screening implementation strategies that incorporate HPV self-sampling options to improve screening access, adherence, and patient satisfaction. The objective of this report is to describe the rationale and design of this pragmatic trial.

Does mailing unsolicited HPV self-sampling kits to women overdue for cervical cancer screening impact uptake of other preventive health services in a United States integrated delivery system?

Women overdue for cervical cancer screening often have other preventive care gaps. We examined whether mailing unsolicited human papillomavirus (HPV) self-sampling kits to increase cervical cancer screening impacted receipt of other preventive services women were due for: mammography, colorectal cancer (CRC) screening, influenza vaccination, depression screening, and diabetic HbA1c monitoring. From 2014 to 2016, 16,590 underscreened women were randomized to receive a mailed kit or usual care Pap reminders within Kaiser Permanente Washington. We used logistic regression to estimate odds ratios (ORs) of preventive services receipt within 12-months between the intervention vs. control arms, and within the intervention arm (comparing those returning a kit vs. attending Pap vs. nothing), adjusting models for demographic variables. There were no significant between-arm differences in uptake of any of the preventive services: intervention vs. control: mammography OR = 1.01 (95% confidence interval:0.88-1.17), CRC screening OR = 0.98 (0.86-1.13), influenza vaccination OR = 0.99 (0.92-1.06), depression screening OR = 1.07 (0.99-1.16), HbA1c OR = 0.84 (0.62-1.13). Within the intervention arm, preventive services uptake was higher in women who completed cervical cancer screening vs. did not, with stronger effects for women who attended Pap: Pap vs. nothing: mammography OR = 11.81 (8.11-17.19), CRC screening OR = 7.31 (5.57-9.58), influenza vaccination OR = 2.06 (1.82-2.32), depression screening OR = 1.79 (1.57-2.05), HbA1c OR = 3.35 (1.49-7.52); kit vs. nothing: mammography OR = 2.26 (1.56-3.26), CRC screening OR = 5.05 (3.57-7.14), influenza vaccination OR = 1.67 (1.41-1.98), depression screening OR = 1.09 (0.89-1.33), HbA1c OR = 1.23 (0.57-2.65). Mailing HPV self-sampling kits to underscreened women did not negatively impact uptake of other preventive services. However, overall preventive service uptake was the highest among women who attended in-clinic cervical cancer screening.

Combined Effect of Health Status and Primary Care Use on Participation in Cancer Screening: The CONSTANCES Cohort

Background:

The combined association between primary care utilization and health status with breast cancer screening (BCS) and cervical cancer screening (CCS) remains unclear. Our aim was to identify women's profiles based on their health status and primary care utilization and study their associated adherence to BCS and CCS recommendations.

Methods:

Using data from the cohort of people visiting health screening centers (CONSTANCES) in France (2012–2015), we first identified women's profiles based on their health status (self-perceived health, physical, and mental health) and primary care utilization (visit to the General Practitioner [GP], uptake of blood tests) using a multiple correspondence analysis and a hierarchical cluster analysis. We then investigated the association of these profiles to BCS and CCS using logistic regression models adjusted for age, smoking status, sociodemographic and socioeconomic characteristics, and the regularity of gynecologist consultation.

Results:

We identified five distinct profiles of women with contrasted participation in BCS (n = 14,122) and CCS (n = 27,120). In multivariate analyses, cancer screening participation increased from women with very good health and poor primary care utilization, to those with poor health and frequent visits to the GP, and those with very good health and average primary care utilization. The most favorable profiles regarding cancer screening rates were women with average-to-poor health and regular visits to the GP and uptake of blood tests.

Conclusions:

Our results suggest that policies aiming at increasing cancer screening participation should simultaneously account for women's use of primary care and health and consider more specific subgroups than what is usually done. Further research should investigate factors motivating cancer screening practice, such as women's beliefs regarding cancer screening and women's psychological characteristics.

Non-participation in cervical cancer screening according to health, lifestyle and sexual behavior: A population-based study of nearly 15,000 Danish women aged 23-45 years

High participation in cervical cancer screening is essential for an effective screening program. In this population-based study, we investigated associations between general health, lifestyle and sexual behavior, and non-participation in cervical cancer screening in Denmark. During 2011-2012, a random sample of women aged 18-45 years from the general female population were invited to participate in a survey regarding health, lifestyle and sexual habits. Altogether 18,631 women responded (response rate: 75.1%), of whom 14,271 women aged 23-45 years were included in this analysis. Information on screening participation within four years after response, and data on sociodemographic characteristics, was obtained from nationwide registers. Logistic regression was used to calculate odds ratios (ORs) for non-participation, crude and adjusted for sociodemographic characteristics. Overall, 13.9% of the women were not screened during follow-up. The odds of non-participation was increased in women who were overweight (OR_adj. = 1.20; 95% CI, 1.06-1.35), obese (OR_adj. = 1.46; 95% CI, 1.27-1.67), perceived themselves as much too fat (OR_adj. = 1.50; 95% CI, 1.29-1.74), had poor self-perceived health (OR_adj. = 1.22; 95% CI, 1.03-1.45) or smoked daily (OR_adj. = 1.81; 95% CI, 1.61-2.03). Conversely, women with previous genital warts or other sexually transmitted infections, and young women with ≥10 lifetime sexual partners or ≥2 new recent partners, had decreased odds of non-participation. In conclusion, obesity, poor self-perceived health and daily smoking were associated with lower participation in cervical cancer screening. Interventions targeting these groups are needed.

Effect of Mailed Human Papillomavirus Test Kits vs Usual Care Reminders on Cervical Cancer Screening Uptake, Precancer Detection, and Treatment: A Randomized Clinical Trial

IMPORTANCE

In the United States, more than 50% of cervical cancers are diagnosed in underscreened women. Cervical cancer screening guidelines now include primary human papillomavirus (HPV) testing as a recommended strategy. Home-based HPV self-sampling is a viable option for increasing screening compliance and effectiveness; however, US data are needed to inform health care system implementation.

OBJECTIVE

To evaluate effectiveness of mailed HPV self-sampling kits vs usual care reminders for in-clinic screening to increase detection and treatment of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and uptake of cervical cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Women aged 30 to 64 years with health plan enrollment for 3 years and 5 months or more, a primary care clinician, no Papanicolaou test within 3 years and 5 months, and no hysterectomy were identified through electronic medical records and enrolled from February 25, 2014, to August 29, 2016, with follow-up through February 26, 2018.

INTERVENTIONS

The control group received usual care (annual patient reminders and ad hoc outreach from primary care clinics). The intervention group received usual care plus a mailed HPV self-sampling kit.

MAIN OUTCOMES AND MEASURES

Two primary outcomes were (1) CIN2+ detection within 6 months of screening and (2) treatment within 6 months of CIN2+ detection. Screening uptake within 6 months of randomization was a secondary outcome.

RESULTS

A total of 19 851 women (mean [SD] age, 50.1 [9.5] years) were included, with 9960 randomized to the intervention group and 9891 randomized to the control group. All women randomized were included in analysis. In the intervention group, 12 participants with CIN2+ were detected compared with 8 in the control group (relative risk, 1.49; 95% CI, 0.61-3.64) and 12 cases were treated vs 7 in the control group (relative risk, 1.70; 95% CI, 0.67-4.32). Screening uptake was higher in the intervention group (2618 participants [26.3%] vs 1719 participants [17.4%]; relative risk, 1.51; 95% CI, 1.43-1.60).

CONCLUSIONS AND RELEVANCE

Mailing HPV kits to underscreened women increased screening uptake compared with usual care alone, with no significant differences in precancer detection or treatment. Results support the feasibility of mailing HPV kits to women who are overdue for screening as an outreach strategy to increase screening uptake in US health care systems. Efforts to increase kit uptake and follow-up of positive results are warranted to maximize detection and treatment of CIN2+.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02005510.

Cervical Cancer, Different Treatments and Importance of Bile Acids as Therapeutic Agents in This Disease

Cervical cancer can be cured, because it has a long preinvasive period. Early diagnosis and treatment of cervical cancer at women are crucial for reducing of rate mortality. Today, there are many methods for detecting premalignant lesions and one of them is a conventional Papanicolaou test. Cervical cancer develops through a series of changes in the epithelium called cervical intraepithelial neoplasia (CIN). The biological and genetic characteristics of the cells at cancer in situ are irreversibly altered and abnormal cells have the potential to metastasize to others anatomical regions. Infection with human Papillomavirus, which is transmitted sexually, is considered the main cause and represent the necessary, but not the only factor for the development of cervical cancer. Types of high risk human Papillomavirus are often associated with invasive cervical cancer. The carcinogenic types of HPV 16 and 18 are responsible for 70% of cervical cancer and about 50% of CIN 3. Primary prevention of cervical cancer is aimed at reducing incidence, control of causes and risk factors. In this scientific work, in addition to explaining the various treatments necessary for the treatment of cervical carcinoma, we were discussed about the anticancer effects of the synthetic derivative of ursodeoxycholic acid, such as HS-1183, and synthetic derivatives of chenodeoxycholic acid such as HS-1199 and HS-1200. Also, the effects of bile acid complexes with metals such as platinum, zinc, nickel, and copper were considered in the effective treatment of cervical cancer.

KEY POINTS

• Lymphogenic spreading of cervical cancer occurs relatively early in the regional lymph nodes, while this sort of progression of cervical cancer is rarer in the juxtaregional (paraaortic), mediastinal and supraclavicular nodes.

Clinically proven supraclavicular metastases are not a rarity. In stages IIb and IIIa with metastases in paraaortal nodes occur a 20% metastases at the neck lymph nodes.

Hematogenic metastases are relatively rare and occur in the posterior phase. Distant metastases are detected in the lungs and liver.

Preinvasive and microinvasive stages of cervical cancer are without symptoms. With deeper invasion of the strome, certain clinical symptoms such as prolonged menstruation, increased vaginal secretions, vaginal bleeding between the two periods, contact bleeding (after coitus), unilateral pelvic pain with spreading in hip joint (infiltration of the pelvic nerve plexus), dysuric disturbance, anemia, islet of the lower extremities.

In order to diagnose the level spreading of primary lesion of cervical cancer most commonly are used the supplemental searches such as cytoscopy, rectoscopy, urography, irigography, lung and bone radiography, scintigraphy of the liver, kidney and bone, lymphography, CT (MR) of abdomen and pelvis, as well as laboratory analysis.

Surgical treatment consists of transvaginal hysterectomy, transabdominal removal of the uterus (via laparotomy), bilateral adenectomy (removal of the ovaries and the fallopian tubes), upper and middle third of the vagina and lymphonodectomy of the regional lymph nodes. The most commonly used radiotherapy, intracavitary brachytherapy, manual afterloading technique and remote afterloading techniques.

The synthetic derivatives of ursodeoxycholic acid and chenodeoxycholic acid such as HS-1183, HS-1199, and HS-1200 are used to treat cervical cancer. These derivatives of chenodeoxycholic acid and ursodeoxycholic acid are capable of inhibiting cell proliferation and inducing apoptosis in SiHa human cells of cervix.

Platinum compounds are used as catalysts in cervical cancer therapy. Clinical use of platinum complexes for which the bile acids bind is based on the desire to achieve the death of tumor cells and the spectrum of drug activity in the treatment of cervical cancer.

Bisursodeoxycholate (ethylenediamine) platinum (II) [Pt(UDC)₂(en)] is characterized by important cytotoxicity against HeLa cervical carcinoma cells and this effect already being clearly detectable after 24 h.

Participation in a Swedish cervical cancer screening program among women with psychiatric diagnoses: a population-based cohort study

Background

In Sweden, organized screening programs have significantly reduced the incidence of cervical cancer. For cancers overall, however, women with psychiatric diagnoses have lower survival rates than other women. This study explores whether women with psychiatric diagnoses participate in cervical cancer screening programs to a lesser extent than women on average, and whether there are disparities between psychiatric diagnostic groups based on grades of severity.

Methods

Between 2000 and 2010, 65,292 women within screening ages of 23–60 had at least two ICD-10 (International Statistical Classification of Diseases and Related Health Problems – Tenth Revision) codes F20*–F40* registered at visits in primary care or psychiatric care in Region Västra Götaland, Sweden. Participation in the cervical cancer screening program during 2010–2014 was compared with the general female population using logistic regression adjusted for age.

Results

Relative risk for participation (RR) for women diagnosed within psychiatric specialist care RR was 0.94 compared with the general population, adjusted for age. RR for diagnoses outside specialist care was 0.99. RR for psychoses (F20*) was 0.81.

Conclusions

Women with less-severe psychiatric diagnoses participate in the screening program to the same extent as women overall. Women who have received psychiatric specialist care participate to a lesser extent than women overall. The lowest participation rates were found among women diagnosed with psychoses.

Factors associated with non-participation in cervical cancer screening - A nationwide study of nearly half a million women in Denmark

Cervical cancer occurs most often in under-screened women. In this nationwide register study, we described differences in sociodemographic characteristics between passive and active non-participants and examined socio-demographic characteristics, reproductive history, and mental and physical health as potential determinants for passive non-participation compared with participation in the Danish cervical cancer screening program. Screening history in women aged 23-49 years invited for cervical cancer screening in 2008-2009 was retrieved from the Danish Pathology Databank with information about dates of invitation and unsubscription. We identified participants (n = 402,984), active non-participants (n = 10,251) and passive non-participants (n = 63,435) within four years following baseline invitation and retrieved data about the study population from high-quality registries. We examined differences in socio-demographic characteristics of passive and active non-participants, and used multiple logistic regression analyses to identify potential determinants of passive non-participation. We found that active and passive non-participants differed in relation to socio-demography. When compared with screening participants, the odds of passive non-participation was increased in women who originated from less developed countries; were unmarried; had basic education or low income; had four or more children; smoked during pregnancy; had multiple induced abortions; or had a history of obesity, intoxicant abuse or schizophrenia or other psychoses. In conclusion, in this nationwide, prospective, population-based study, differences in socio-demographic characteristics between passive and active non-participants were found. Furthermore, sociodemography, reproductive history, and mental and physical health were determinants for passive non-participation. Addressing inequalities in screening attendance may help to further decrease the incidence of and mortality from cervical cancer.

Self-Sampling for Human Papillomavirus Testing: Increased Cervical Cancer Screening Participation and Incorporation in International Screening Programs

In most industrialized countries, screening programs for cervical cancer have shifted from cytology (Pap smear or ThinPrep) alone on clinician-obtained samples to the addition of screening for human papillomavirus (HPV), its main causative agent. For HPV testing, self-sampling instead of clinician-sampling has proven to be equally accurate, in particular for assays that use nucleic acid amplification techniques. In addition, HPV testing of self-collected samples in combination with a follow-up Pap smear in case of a positive result is more effective in detecting precancerous lesions than a Pap smear alone. Self-sampling for HPV testing has already been adopted by some countries, while others have started trials to evaluate its incorporation into national cervical cancer screening programs. Self-sampling may result in more individuals willing to participate in cervical cancer screening, because it removes many of the barriers that prevent women, especially those in low socioeconomic and minority populations, from participating in regular screening programs. Several studies have shown that the majority of women who have been underscreened but who tested HPV-positive in a self-obtained sample will visit a clinic for follow-up diagnosis and management. In addition, a self-collected sample can also be used for vaginal microbiome analysis, which can provide additional information about HPV infection persistence as well as vaginal health in general.

Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study

Background

Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure.

Objective

Identify socio-economic and demographic determinants for non-attendance in cervical screening.

Methods

Design: Population-based case-control study.

Setting: Sweden.

Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30–60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6–8 years. The control group (N = 266,706) attended within 90 days of invitation.

Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables.

Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated.

Results

Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01–2.11), with low education (adjOR 1.77; CI 1.73–1.81) and not cohabiting (adjOR 1.47; CI 1.45–1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06–4.35) to OR 0.54 (CI 0.52–0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors.

Conclusion

County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Rationale and design of the HOME trial: A pragmatic randomized controlled trial of home-based human papillomavirus (HPV) self-sampling for increasing cervical cancer screening uptake and effectiveness in a U.S. healthcare system

Women who delay or do not attend Papanicolaou (Pap) screening are at increased risk for cervical cancer. Trials in countries with organized screening programs have demonstrated that mailing high-risk (hr) human papillomavirus (HPV) self-sampling kits to under-screened women increases participation, but U.S. data are lacking. HOME is a pragmatic randomized controlled trial set within a U.S. integrated healthcare delivery system to compare two programmatic approaches for increasing cervical cancer screening uptake and effectiveness in under-screened women (>3.4years since last Pap) aged 30-64years: 1) usual care (annual patient reminders and ad hoc outreach by clinics) and 2) usual care plus mailed hrHPV self-screening kits. Over 2.5years, eligible women were identified through electronic medical record (EMR) data and randomized 1:1 to the intervention or control arm. Women in the intervention arm were mailed kits with pre-paid envelopes to return samples to the central clinical laboratory for hrHPV testing. Results were documented in the EMR to notify women's primary care providers of appropriate follow-up. Primary outcomes are detection and treatment of cervical neoplasia. Secondary outcomes are cervical cancer screening uptake, abnormal screening results, and women's experiences and attitudes towards hrHPV self-sampling and follow-up of hrHPV-positive results (measured through surveys and interviews). The trial was designed to evaluate whether a programmatic strategy incorporating hrHPV self-sampling is effective in promoting adherence to the complete screening process (including follow-up of abnormal screening results and treatment). The objective of this report is to describe the rationale and design of this pragmatic trial.

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.

Why Do Chilean Women Choose to Have or Not Have Pap Tests?

OBJECTIVE

To describe the perceptions of Chilean women about why women choose to have or not have Pap test screening.

DESIGN

Qualitative research using content analysis according to Krippendorf.

SETTING

Four urban health clinics in Santiago, Chile.

PARTICIPANTS

Fifty-seven Chilean women.

METHODS

Audiotaped focus groups.

RESULTS

Six themes emerged: Reasons that make it difficult for women to schedule appointments, Characteristics of health professionals that make it difficult to have a Pap test, Characteristics of the test that are barriers to having a Pap test, The relationship of the test with cancer, Family context, and Each woman's personal characteristics.

CONCLUSION

Primary health care providers play an important role in promoting adherence to cervical cancer screening. Nurses should proactively address women's perceptions and knowledge about screening and openly and uniformly discuss the importance and benefits of Pap test screening.

Increasing attendance in a cervical cancer screening programme by personal invitation: experience of a Lithuanian primary health care centre

BACKGROUND

High participation rates are an essential component of an effective screening programme and many approaches were introduced as being successful for enhancing compliance to screening guidelines. The aim of this study was to evaluate to which extent a personal invitation by mail increases the rate of attendance in a cervical cancer screening programme in a primary health care centre.

MATERIALS AND METHODS

The study was carried out as a pilot project to gain insight into feasibility of applying a well-known compliance increasing measure in Lithuanian population. The study included a sample of women registered at the primary health care centre in Panevėžys who had not participated in the cervical cancer screening programme for six and more years. Personal registered invitation letters to attend the primary health care centre for a Pap smear were sent out to 1789 women by mail.

RESULTS

In total, 2195 women were tested during 2011 at the primary health care centre. 487 (22.2%) of them attended the screening programme after receiving a personal invitation letter. Response rate for attending screening after receiving a personal invitation letter was 27.3%.

CONCLUSIONS

Our study demonstrated that personal invitation letters addressed to long-term non-attendees could markedly increase participation in cervical cancer screening in Lithuania.

Trends in Participation Rates for the National Cancer Screening Program in Korea, 2002-2012

Purpose

The National Cancer Screening Program (NCSP) in Korea supports cancer screening for stomach, liver, colorectal, breast, and cervical cancer. This study was conducted to assess trends in participation rates among Korean men and women invited to undergo screening via the NCSP as part of an effort to guide future implementation of the program in Korea.

Materials and Methods

Data from the NCSP for 2002 to 2012 were used to calculate annual participation rates with 95% confidence intervals (CI) by sex, insurance status, and age group for stomach, liver, colorectal, breast, and cervical cancer screening.

Results

In 2012, participation rates for stomach, liver, colorectal, breast, and cervical cancer screening were 47.3%, 25.0%, 39.5%, 51.9%, and 40.9%, respectively. The participation rates increased annually by 4.3% (95% CI, 4.0 to 4.6) for stomach cancer, 3.3% (95% CI, 2.5 to 4.1) for liver cancer, 4.1% (95% CI, 3.2 to 5.0) for colorectal cancer, 4.6% (95% CI, 4.1 to 5.0) for breast cancer, and 0.9% (95% CI, –0.7 to 2.5) for cervical cancer from 2002 to 2012.

Conclusion

Participant rates for the NCSP for the five above-mentioned cancers increased annually from 2002 to 2012.

Self-Sampling for Human Papillomavirus Testing among Non-Attenders Increases Attendance to the Norwegian Cervical Cancer Screening Programme

Increasing attendance to screening offers the best potential for improving the effectiveness of well-established cervical cancer screening programs. Self-sampling at home for human papillomavirus (HPV) testing as an alternative to a clinical sampling can be a useful policy to increase attendance. To determine whether self-sampling improves screening attendance for women who do not regularly attend the Norwegian Cervical Cancer Screening Programme (NCCSP), 800 women aged 25–69 years in the Oslo area who were due to receive a 2^nd reminder to attend regular screening were randomly selected and invited to be part of the intervention group. Women in this group received one of two self-sampling devices, Evalyn Brush or Delphi Screener. To attend screening, women in the intervention group had the option of using the self-sampling device (self-sampling subgroup) or visiting their physician for a cervical smear. Self-sampled specimens were split and analyzed for the presence of high-risk (hr) HPV by the CLART® HPV2 test and the digene® Hybrid Capture (HC)2 test. The control group consisted of 2593 women who received a 2^nd reminder letter according to the current guidelines of the NCCSP. The attendance rates were 33.4% in the intervention group and 23.2% in the control group, with similar attendance rates for both self-sampling devices. Women in the self-sampling subgroup responded favorably to both self-sampling devices and cited not remembering receiving a call for screening as the most dominant reason for previous non-attendance. Thirty-two of 34 (94.1%) hrHPV-positive women in the self-sampling subgroup attended follow-up. In conclusion, self-sampling increased attendance rates and was feasible and well received. This study lends further support to the proposal that self-sampling may be a valuable alternative for increasing cervical cancer screening coverage in Norway.

Effect of Fee on Cervical Cancer Screening Attendance--ScreenFee, a Swedish Population-Based Randomised Trial

BACKGROUND

Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme.

METHOD

Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.

RESULTS

Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.

CONCLUSION

Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02378324.

Priority Setting for Improvement of Cervical Cancer Prevention in Iran

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide. Organized cervical screening and vaccination against human papilloma virus (HPV) have been successful interventions for prevention of invasive cervical cancer (ICC). Because of cultural and religious considerations, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention of ICC in this setting.

METHODS

We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go-zone analysis to determine final list of priorities for ICC prevention in Iran.

RESULTS

From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management of precancerous lesions. In addition, we emphasized considering insurance coverage for cervical screening, public awareness, and research priorities, and establishment of a cervical screening registry.

CONCLUSION

A comprehensive approach and implementation of organized cervical screening program is necessary for prevention of ICC in Iran and other low incidence Muslim countries. Because of high cost for vaccination and low incidence of cervical cancer, we do not recommend HPV vaccination for the time being in Iran.

Impact of opportunistic testing in a systematic cervical cancer screening program: a nationwide registry study

BACKGROUND

Systematic screening for precancerous cervical lesions has resulted in decreased incidence and mortality of cervical cancer. However, even in systematic screening programs, many women are still tested opportunistically. This study aimed to determine the spread of opportunistic testing in a systematic cervical cancer screening program, the impact of opportunistic testing in terms of detecting cytological abnormalities and examine the associations between sociodemography and opportunistic testing.

METHODS

A nationwide registry study was undertaken including women aged 23-49 years (n = 807,624) with a cervical cytology between 2010 and 2013. The women were categorised into: 1) screening after invitation; 2) routine opportunistic testing, if they were either tested more than 9 months after the latest invitation or between 2.5 years and 3 years after the latest cervical cytology and 3) sporadic opportunistic testing, if they were tested less than 2.5 years after the latest cervical cytology. Cytological diagnoses of women in each of the categories were identified and prevalence proportion differences (PPD) and 95% confidence intervals (CIs) were used to explore group differences. Associations between sociodemography and undergoing opportunistic testing were established by multinomial logistic regression.

RESULTS

In total, 28.8% of the cervical cytologies were due to either routine (20.7%) or sporadic (8.1%) opportunistic testing. Among women undergoing routine opportunistic testing, a larger proportion had high-grade squamous intraepithelial abnormalities than invited women (PPD: 0.6%, 95 % CI: 0.03-1.17%). A similar proportion of cytological abnormalities among women undergoing sporadic opportunistic testing and invited women was found. In multivariate analyses, younger age, being single or a social welfare recipient and residence region (North Denmark) were especially associated with opportunistic testing (routine or sporadic).

CONCLUSIONS

One fourth of cervical cytologies in this study were collected opportunistically. Compared to invited women, women undergoing routine opportunistic testing were more likely to be diagnosed with abnormal cytologies. Hence, routine opportunistic testing might serve as an important supplement to the systematic screening program by covering non-participating women who may otherwise be tested with a delay or not tested at all. Among women tested more often than recommended (sporadic testing), no benefits in terms of detecting more cytological abnormalities were identified.

Immigrant women's experiences and views on the prevention of cervical cancer: a qualitative study

BACKGROUND

Many Western countries have cervical cancer screening programmes and have implemented nation-wide human papillomavirus (HPV) vaccination programmes for preventing cervical cancer.

OBJECTIVE

To explore immigrant women's experiences and views on the prevention of cervical cancer, screening, HPV vaccination and condom use.

DESIGN

An exploratory qualitative study. The Health Belief Model (HBM) was used as a theoretical framework.

SETTING AND PARTICIPANTS

Eight focus group interviews, 5-8 women in each group (average number 6,5), were conducted with 50 women aged 18-54, who studied Swedish for immigrants. Data were analysed by latent content analysis.

RESULTS

Four themes emerged: (i) deprioritization of women's health in home countries, (ii) positive attitude towards the availability of women's health care in Sweden, (iii) positive and negative attitudes towards HPV vaccination, and (iv) communication barriers limit health care access. Even though the women were positive to the prevention of cervical cancer, several barriers were identified: difficulties in contacting health care due to language problems, limited knowledge regarding the relation between sexual transmission of HPV and cervical cancer, culturally determined gender roles and the fact that many of the women were not used to regular health check-ups.

CONCLUSION

The women wanted to participate in cervical cancer prevention programmes and would accept HPV vaccination for their daughters, but expressed difficulties in understanding information from health-care providers. Therefore, information needs to be in different languages and provided through different sources. Health-care professionals should also consider immigrant women's difficulties concerning cultural norms and pay attention to their experiences.

Uptake of colorectal cancer screening among Ontarians with intellectual and developmental disabilities

Under-screening for cancer may contribute to a greater disease burden in individuals with intellectual and developmental disabilities (IDD) as their life expectancy increases. In 2008, the province of Ontario launched Canada’s first population-based colorectal cancer screening program. Our objectives were to compare the proportions of Ontarians with and without IDD who have undergone colorectal cancer screening and to examine factors associated with screening uptake among Ontarians with IDD. Records for Ontario residents 50–64 years of age were linked across various administrative health and social services datasets to identify individuals with IDD and to select a random sample of the age-equivalent Ontario population without IDD as a comparison group. Logistic regression models were fit to examine the odds of screening uptake among individuals with IDD while controlling for age, sex, urban or rural residence, neighbourhood income quintile, expected use of health care resources, and being enrolled with or seeing a physician in a patient enrolment model (any of several primary care practice models designed to improve patient access and quality of care in Ontario), and to examine the association between these variables and colorectal cancer screening in the IDD population. The odds of having had a fecal occult blood test in the previous two years and being up-to-date with colorectal tests were 32% and 46% lower, respectively, for Ontarians with IDD compared to those without IDD. Being older, female, having a greater expected use of health care resources, and being enrolled with or seeing a physician in a primary care patient enrolment model were all significantly associated with higher odds of having been screened for colorectal cancer in the IDD population. These findings underscore the need for targeted interventions aimed at making colorectal cancer screening more equitable.

A prospective double-blind cross-sectional study of the accuracy of the use of dry vaginal tampons for self-sampling of human papillomaviruses

OBJECTIVE

To evaluate if a dry vaginal tampon can be used to accurately detect high-risk human papillomaviruses (HPV) and so be used as a cervical screening tool for the early detection of high-grade cervical intraepithelial neoplasia (CIN2+).

DESIGN

Prospective double-blinded cross-sectional study.

SETTING

Colposcopy unit in North London.

POPULATION

Women referred for colposcopy with both abnormal and normal cervical cytology were invited to participate in this study.

METHODS

Women inserted a dry tampon in the vagina before colposcopic examination. Polymerase chain reaction (PCR) HPV test was carried out on the dry tampon. Cervical samples were collected by the colposcopist for HPV testing using Hybrid Capture (an HC2 kit).

MAIN OUTCOME MEASURE

Detection of CIN2+.

RESULTS

In all, 501 women participated in the study. The majority of participants (69%) were in the 25-35-year age group. Overall sensitivity and specificity for detection of CIN2+ by vaginal tampon were 76% (95% confidence interval [95% CI] 65-85) and 61% (95% CI 56-66), respectively, and HC2 had a sensitivity of 92% (95% CI 83-97) with a specificity of only 46% (95% CI 41-51). Sensitivity ratio was 0.83 (95% CI 0.73-0.94) (P = 0.004) and Specificity ratio for CIN2+ was 1.33 (95% CI 1.22-1.45). Indicating that the tampon test was significantly (P < 0.0001) more specific. Sensitivity decreased and specificity improved with increasing age.

CONCLUSIONS

Dry tampon test showed reasonably high sensitivity and specificity when detecting CIN2+. The majority of participants (98%) approved of the use of dry tampons as a method of sample collection, which could be an effective alternative method for detecting HPV infection.

Barriers to cancer screening among medical aid program recipients in the Republic of Korea: a qualitative study

Few studies have examined reasons why those with low socioeconomic status do not adequately receive cancer screening. We therefore conducted a qualitative study to assess the barriers to cancer screening in people with low socioeconomic status, and to examine the reasons why Medical Aid Program (MAP) recipients do not participate in the National Cancer Screening Program (NCSP). A focus group methodology was used. Participants included MAP recipients (men aged 45-79 years, women aged 35-79 years) who had been invited to cancer screening at least twice based on the NCSP protocol, but had not been screened for any cancer from 2009-2012. We recruited participants living in the cities of Goyang and Paju. A total of 23 MAP recipients participated in four focus group discussions, including 12 men and 11 women. In this qualitative study, we identified six barriers to screening: lack of trust in the NCSP and cancer screening units; fear of being diagnosed with cancer; discomfort or pain from the screening procedure; lack of time, lack of knowledge about cancer screening or lack of awareness of the existence of the NCSP; physical disability or underlying disease; and logistic barriers. Interventions such as individualized counseling, letters and reminders, or other individually-targeted strategies, especially for those with lower socioeconomic status are required to increase participation and reduce disparities in cancer screening.

Improving cervical cancer screening attendance in Finland

High attendance is essential to cervical cancer screening results. Attendance in the Finnish program is currently at 70%, but extensive opportunistic screening occurs beside the organized. A shift from opportunistic to organized screening is imperative to optimize the costs and impact of screening and minimize potential harms. We evaluated the effect of reminder letters (1st reminder) and self-sampling test (2nd reminder) on program attendance. The study population consisted of 31,053 screening invitees in 31 Finnish municipalities. 8,284 non-attendees after one invitation received a reminder letter and 4,536 further non-attendees were offered a self-sampling option. Socioeconomic factors related to participation were clarified by combining screening data to data from Statistics Finland. Reminder letters increased participation from 72.6% (95% CI 72.1, 73.1) to 79.2% (95% CI 78.8, 79.7) and self-sampling further to 82.2% (95% CI 81.8, 82.7). Reminder letters with scheduled appointments resulted in higher increase than open invitations (10 vs. 6%). Screening of original non-attendees increased the yield of CIN3+ lesions by 24%. Non-attendance was associated with young age, immigrant background, lower education level and having never been married. We showed that a total attendance of well over 80% can be achieved within an organized program when the invitational protocol is carefully arranged.

Attending cervical cancer screening, opportunities and obstacles: a qualitative study on midwives' experiences telephoning non-attendees in Sweden

AIM

As part of a research project aimed at increasing participation in the cervical cancer screening program (CCS), we explored midwives' unique experiences of telephoning non-attendees and offering Pap smear appointments.

METHODS

Twenty midwives, in four focus groups, discussed their experiences of a study investigating ways to increase participation in the CCS. The group discussions were tape-recorded and transcribed verbatim and underwent qualitative content analysis.

RESULTS

Speaking with more than 1000 non-attendees provided the midwives with new perspective on the CCS and they realised that improving it might address a number of reasons for not participating. These reasons were often related to logistics, such as scheduling flexibility and appointment booking. The telephone conversations revealed that some women required more individual attention, while it was discovered that others did not require screening. The midwives considered the CCS to be life-saving; participating in this screening activity gave them a sense of satisfaction and pride.

CONCLUSIONS

This study shows that midwives can improve access and prevent non-attendance at the cervical cancer screening program when they are aware of women's varying requirements for attending screening.

Does the primary screening test influence women's anxiety and intention to screen for cervical cancer? A randomized survey of Norwegian women

BACKGROUND

Countries must decide whether or not to replace primary cytology-based screening with primary human papillomavirus (HPV)-based screening. We aimed to assess how primary screening for an HPV infection, a sexually transmitted infection (STI), and the type of information included in the invitation letter, will affect screening intention.

METHODS

We randomized a representative sample of Norwegian women to one of three invitation letters: 1) Pap smear, 2) HPV testing or 3) HPV testing with additional information about the nature of the infection. Intention to participate, anxiety level and whether women intend to follow-up abnormal results were measured between groups using chi-squared and nonparametric Kruskal-Wallis tests. Determinants of intention were explored using logistic regression.

RESULTS

Responses from 3540 women were representative of the Norwegian population with respect to age, civil status and geographic location. No significant difference across invitation letters was found in women's stated intention to participate (range: 91.8-92.3%), anxiety (39-42% were either quite or very worried) or to follow-up after an abnormal result (range: 97.1-97.6%). Strength of intention to participate was only marginally lower for HPV-based invitation letters, albeit significant (p-value = 0.008), when measured on a scale. Only 36-40% of respondents given the HPV invitations correctly understood that they likely had an STI.

CONCLUSIONS

We found that switching to primary HPV screening, independent of additional information about HPV infections, is not likely to reduce screening participation rates or increase anxiety; however, women lacked the ability to interpret the meaning of an HPV-test result.

Disseminating a cervical cancer screening program through primary physicians in Hong Kong: a qualitative study

BACKGROUND

Organized screening programs are more effective and equitable than opportunistic screening, yet governments face challenges to implement evidence-based programs. The objective of this study was to identify reasons for low levels of adoption among primary care physicians of a government sponsored Cervical Screening Program (CSP).

METHODS

We conducted in-depth interviews with a snowball sample of primary care private and public primary care physicians in Hong Kong. Rogers' theory of diffusion of innovation was used to understand the factors that influenced the physicians' practice decisions.

RESULTS

Our study found that Hong Kong physicians made the decision to encourage cervical screening and to participate in the CSP based primarily upon their clinical and business practice needs rather than upon the scientific evidence. The low rates of adoption of the CSP can be attributed to the physicians' perceptions that the program's complexity and incompatibility exceeded its relative advantages. Furthermore, women's knowledge, attitudes and practices, identified as barriers by physicians, were also barriers to physicians adopting the CSP.

CONCLUSIONS

In both private and public health care systems, screening programs that rely on physicians must align program incentives with the physicians' motivators or pursue additional demand creation policies to achieve objectives.

Media complementarity and health information seeking in Puerto Rico

This investigation incorporates the Orientation1-Stimulus-Orientation2-Response model on the antecedents and outcomes of individual-level complementarity of media use in health information seeking. A secondary analysis of the Health Information National Trends Survey Puerto Rico data suggests that education and gender were positively associated with individual-level media complementarity of health information seeking, which, in turn, was positively associated with awareness of health concepts and organizations, and this awareness was positively associated with a specific health behavior: fruit and vegetable consumption. This study extends the research in media complementarity and health information use; it provides an integrative social psychological model empirically supported by the Health Information National Trends Survey Puerto Rico data.

Comparison of use of vaginal HPV self-sampling and offering flexible appointments as strategies to reach long-term non-attending women in organized cervical screening

BACKGROUND

Many cervical cancers occur among women who have not attended cervical screening. Strategies to reach non-attending women may improve the effectiveness of cervical screening programmes.

OBJECTIVE

To compare the responses among long-term non-attending women to either (i) HPV-testing of a self-collected vaginal sample, or (ii) cytological screening with a flexible no-fee appointment for sampling at an outpatient clinic.

STUDY DESIGN

Among the 242,000 women aged 32-65 years in Southern Sweden, we identified 28,635 women who had not had any cervical smears taken for >9 years. We randomized 1000 women to invitation to HPV self-sampling, and 500 women to flexible outpatient clinic appointments. Responding women received a questionnaire about their reasons for previous non-attendance.

RESULTS

The response rate to HPV self-sampling was three times higher than the flexible outpatient clinic invitations (147/1000 women (14.7%) compared to 21/500 (4.2%) p<0.0001). High-risk (hr)-HPV was found in 10/147 self-sampled women (6.9%). 7/10 hr-HPV-positive women attended colposcopy, but no HSIL was found. Among the clinic-sampled women, 2/21 had hr-HPV and 1/21 had HSIL. Reasons for not attending were "uncomfortable with vaginal examination", "feel healthy", "lack of time" and "experience of unfriendly health workers".

CONCLUSIONS

Although the response rate was low for both interventions, the invitation to vaginal HPV self-sampling was more effective for increasing the coverage of the screening programme. The fact that "uncomfortable with vaginal examination" was the most common reason for non-attending suggests that self-sampling could be further explored as a strategy to increase the coverage of cervical screening programmes.

Are cervical and breast cancer screening programmes equitable? The case of women with intellectual and developmental disabilities

BACKGROUND

Effective cancer screening must be available for all eligible individuals without discrimination. Lower rates of cervical and breast cancer screening have been reported in certain groups compared with women from the general population, such as women with intellectual and developmental disabilities (IDD). Research on the factors explaining those observed differences is crucial to determine whether practices are unfair and could be improved. The aim of this population-based study was to describe cancer screening utilisation by women with IDD in Ontario, Canada compared with other women in Ontario. The specific objectives were (1) to estimate the rates of cervical and breast cancer screening among eligible women with IDD in Ontario; (2) to compare the rates of cervical and breast cancer screening between eligible women with and without IDD; and (3) to examine if any observed differences between women with and without IDD persist after factors such as age, socio-economic status, rurality and healthcare utilisation are accounted for.

METHOD

This study draws women with IDD from an entire population, and draws a randomly selected comparison group from the same population. It controls for important confounders in cancer screening within the limitations of the data sources. The study was conducted using health administrative databases and registries in Ontario, Canada. Two cohorts were created: a cohort of all women identified as having an IDD and a cohort consisting of a random sample of 20% of the women without IDD.

RESULTS

The proportion of women with IDD who are not screened for cervical cancer is nearly twice what it is in the women without IDD, and 1.5 times what it is for mammography.

CONCLUSIONS

Findings suggest that women with IDD experience inequities in their access to cancer screening. Public health interventions targeting this population should be implemented.

Avoiding piecemeal research on participation in cervical cancer screening: the advantages of a social identity framework

BACKGROUND

Cervical cancer screening research has predominantly focused on one type of participation, namely compliance with medical recommendations, and has largely ignored other types of participation. While there is some research that has taken a different approach, findings in this research area are not well integrated under a theoretical framework.

OBJECTIVE

The aim of this study is to show how consideration of a broader definition of participation and better integration of the theoretical conceptualization of participation in cervical cancer screening are both possible and desirable to enable a better understanding of women's experiences of cervical cancer screening specifically and to improve women's health generally.

MAIN CONCLUSION

It is suggested that alternative types of participation in cervical cancer screening warrant further investigation and that a social identity theoretical approach offers one way of integrating such conceptualizations of participation. The paper also argues for more explicit consideration of the role of social processes and of the variables, such as power, social identity and relational justice, which are involved in participation in cervical cancer screening.

Cervical cancer in the screening era: who fell victim in spite of successful screening programs?

Objective

To compare profiles of a prescreening and screening cohort of women with cervical cancer regarding histopathology and clinical variables in order to identify those remaining at risk despite successful screening programs. By analyzing these profiles we hope to improve future screening methods.

Methods

The prescreening and screening cohorts consisted of 5,046 and 1,174 women, respectively, treated for cervical cancer at the Department of Gynecological Oncology at Radiumhemmet, Karolinska University Hospital, during the periods 1944-1957 and 1990-2004.

Results

Mean age increased from 48.9 years to 55.3 years in the cohorts treated 1944-1957 and 1990-2004, respectively. The percentage of patients older than 69 years was 5.4% and 27.3% in the prescreening and screening period, respectively. A shift towards earlier stages at diagnosis, a reduction of squamous cervical cancer and an increase of adenocarcinoma were observed in the screening cohort. The percentage of adenocarcinoma was about 6 times higher among younger patients. Cases of stump cancer and cervical cancer associated with pregnancy have declined. Eighty-seven women in the screening cohort had a history of treatment for in situ carcinoma by conization; 28% of these cases developed cervical cancer within one year after conization.

Conclusion

The profile changed in the screening era indicating a need to refine screening for improved detection of in older women. This study, one of the largest clinical series of cervical cancer, provides an important baseline with which later studies can be compared to evaluate the effects of human papillomavirus vaccine and other important changes in this field.

Association between sexual behavior and cervical cancer screening

BACKGROUND

Not much is known about whether women who follow Pap testing recommendations report the same pattern of sexual behavior as women who do not.

METHODS

Data come from part of a larger population-based computer-assisted telephone survey of 8656 Australians aged 16-64 years resident in Australian households with a fixed telephone line (Australian Longitudinal Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a Pap test in the past 2 years.

RESULTS

Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal intercourse) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years. Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the past 2 years.

CONCLUSIONS

There are differences in Pap testing behavior among Australian women related to factors that may affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to report a recent test. Screening programs should consider the need to focus recruitment strategies for these women.

Sociodemographic gradients in breast and cervical cancer screening in Korea: the Korean National Cancer Screening Survey (KNCSS) 2005-2009

Background

Cancer screening rates in Korea for five cancer types have increased steadily since 2002. With regard to the life-time cancer screening rates in 2009 according to cancer sites, the second highest was breast cancer (78.1%) and the third highest was cervical cancer (76.1%). Despite overall increases in the screening rate, disparities in breast and cervical cancer screening, based on sociodemographic characteristics, still exist.

Methods

Data from 4,139 women aged 40 to74 years from the 2005 to 2009 Korea National Cancer Screening Survey were used to analyze the relationship between sociodemographic characteristics and receiving mammograms and Pap smears. The main outcome measures were ever having had a mammogram and ever having had a Pap smear. Using these items of information, we classified women into those who had had both types of screening, only one screening type, and neither screening type. We used logistic regression to investigate relationships between screening history and sociodemographic characteristics of the women.

Results

Being married, having a higher education, a rural residence, and private health insurance were significantly associated with higher rates of breast and cervical cancer screening after adjusting for age and sociodemographic factors. Household income was not significantly associated with mammograms or Pap smears after adjusting for age and sociodemographic factors.

Conclusions

Disparities in breast and cervical cancer screening associated with low sociodemographic status persist in Korea.

Factors associated with non-attendance, opportunistic attendance and reminded attendance to cervical screening in an organized screening program: a cross-sectional study of 12,058 Norwegian women

BACKGROUND

Cervical cancer incidence and mortality may be reduced by organized screening. Participant compliance with the attendance recommendations of the screening program is necessary to achieve this. Knowledge about the predictors of compliance is needed in order to enhance screening attendance.

METHODS

The Norwegian Co-ordinated Cervical Cancer Screening Program (NCCSP) registers all cervix cytology diagnoses in Norway and individually reminds women who have no registered smear for the past three years to make an appointment for screening. In the present study, a questionnaire on lifestyle and health was administered to a random sample of Norwegian women. The response rate was 68%. To address the predictors of screening attendance for the 12,058 women aged 25-45 who were eligible for this study, individual questionnaire data was linked to the cytology registry of the NCCSP. We distinguished between non-attendees, opportunistic attendees and reminded attendees to screening for a period of four years. Predictors of non-attendance versus attendance and reminded versus opportunistic attendance were established by multivariate logistic regression.

RESULTS

Women who attended screening were more likely than non-attendees to report that they were aware of the recommended screening interval, a history of sexually transmitted infections and a history of hormonal contraceptive and condom use. Attendance was also positively associated with being married/cohabiting, being a non-smoker and giving birth. Women who attended after being reminded were more likely than opportunistic attendees to be aware of cervical cancer and the recommended screening interval, but less likely to report a history of sexually transmitted infections and hormonal contraceptive use. Moreover, the likelihood of reminded attendance increased with age. Educational level did not significantly affect the women's attendance status in the fully adjusted models.

CONCLUSIONS

The likelihood of attendance in an organized screening program was higher among women who were aware of cervical screening, which suggests a potential for a higher attendance rate through improving the public knowledge of screening. Further, the lower awareness among opportunistic than reminded attendees suggests that physicians may inform their patients better when smears are taken at the physician's initiative.

Reasons why women choose a medical practice or a women's health centre for routine health screening: worker and client perspectives

AIMS AND OBJECTIVES

This article aims to explore the stories and perceptions of consumers and health care workers in an area with a low uptake rate of women's health screening. Further, this article explores what factors influence women's choices for women's health screening in relation to the type of services they access.

BACKGROUND

Routine women's health screening, using mammography and Papanicolaou (Pap) testing, is known to assist in the early detection of cancer and thereby has the potential to increase positive health outcomes for women. However, traditionally, compliance rates to women's health screening are lower than desired because of multiple barriers. Previous studies have largely been quantitative and few have been conducted in areas of low compliance to women's health screening. Furthermore, previous research has not identified the type of service offered, or gender of the professional providing this service, as potential barriers to women's health screening.

DESIGN

Qualitative, storytelling design.

METHOD

Participants from a socioeconomically disadvantaged area were recruited into the study via media releases. Data were collected during conversational, face to face interviews which were between 30 and 90 minutes in duration, digitally recorded and transcribed verbatim. During the process of analysis, dominant stories became obvious through the repetition or emphasis of women's accounts, and it is these stories that are presented in the findings.

RESULTS

Findings suggest that women's decisions about care for routine health screening are guided by three major concerns. Women are seeking a woman friendly and woman-centred service, a safe environment and continuity of care. All these factors informed women's decision-making around where to seek care for routine health screening.

CONCLUSIONS

Additional specialised women's health services are required to meet the needs of women. The provision of accessible women-centred environments has the potential to enhance compliance with women's health screening.

RELEVANCE TO CLINICAL PRACTICE

It is possible that generalist medical practises as well as specialised women's health centres can provide woman-centred care. This as well as further access to education and training that supports nurses to become specialised competent and confident women's health practitioners may enhance screening rates.

Cervical cancer screening: knowledge, health perception and attendance rate among Hong Kong Chinese women

Purpose:

Cervical cancer screening has been consistently shown to be effective in reducing the incidence rate and mortality from cervical cancer. However, cervical screening attendance rates are still far from satisfactory in many countries. Strategies, health promotion and education programs need to be developed with clear evidence of the causes and factors relating to the low attendance rate. The study aims to assess the prediction of cervical screening attendance rate by Chinese women’s knowledge about cervical cancer and cervical screening as well as their perception of health.

Patients and methods:

A survey with self-reported questionnaires was conducted on 385 Chinese women recruited from a community clinic in Hong Kong. Participants were Chinese women, Hong Kong residents, aged 18–65 years, able to read Chinese or English, and were not pregnant.

Results:

Women aged 37 years or less, with at least tertiary education, who perceived having control over their own health and had better knowledge on risk factors, were more likely to attend cervical cancer screening. Many participants had adequate general knowledge but were unable to identify correct answers on the risk factors.

Conclusion:

Health promotion efforts need to focus on increasing women’s knowledge on risk factors and enhancing their perceived health control by providing more information on the link between screening and early detection with lower incidence rates and mortality from cervical cancer.

Does participation to screening unintentionally influence lifestyle behaviour and thus lifestyle-related morbidity?

Cancer is a leading cause of death worldwide and the burden could be reduced by evidence-based strategies for the primary prevention of cancer, the early detection of malignancies and more adequate treatment of cancer patients. Previous research has shown that lifestyle factors are associated with common cancers and that several cancer screening programmes are cost-effective in reducing cancer-specific mortality. But, some recent studies reported that participants of screening programs might unintentionally change their lifestyle. Cancer screening might be a teachable moment or, on the other hand, have a false health certificate effect. Despite that the evidence is scarce, cancer screening might have opportunities for lifestyle improvements, although a possible health certificate effect still remains. Integrated approaches to combine primary and secondary prevention have the potential to optimise the efforts to improve cancer prevention and survival. More research is warranted to investigate evidence-based approaches.