Cervical cancer incidence in elderly women-biology or screening history?

The use of colposcopy for triage in HPV-positive women aged 65 years and older

PURPOSE

Persistent high-risk HPV infection is associated with an elevated risk for prevalent CIN II + despite normal cytology (NILM). Our study aims to evaluate the clinical relevance of a persistent high-risk HPV infection without cytologic changes in women aged ≥ 65 and to determine the role of colposcopy for triage in these cases.

METHODS

211 patients aged ≥ 65 with persistent HPV infection and normal cytology (NILM) who presented for colposcopy at five certified centers between January 2021 and April 2022 were included in the study. Colposcopic findings, HPV subtypes, when available, histology and p16/Ki67 staining were assessed as well as individual risk factors such as smoking and previous HPV-related surgery.

RESULTS

87.7% (185/211) of the included women had a type 3 transformation zone. In 83.4% (176/211), a biopsy was taken [thereof 163 endocervical curettages (ECC)]. In 35/211 women (16.6%), sampling was not possible during colposcopy due to an inaccessible cervix, pain during examination or obliteration of the cervical canal. Out of these, 6 women received a diagnostic excision. CIN II + was detected in 10.6% of all histologies (excisional or biopsy) (20/182). 50% of the women with a CIN II + where HPV 16 positive. Taking only the women diagnosed with CIN III or AIS into account, (n = 12) 75% were HPV 16 positive. Interestingly, 80% of the women with CIN II + had an abnormal cytology when repeatedly taken during colposcopy, vice versa an endocervical lesion was diagnosed in 53% of women with abnormal repeat cytology (27/51).

CONCLUSION

The prevalence of CIN II + in women is ≥ 65 with persistent hr HPV infection but NILM cytology is similar to that in younger women. However, more than 85% of the women have a type 3 transformation zone. Colposcopy is, therefore, not helpful to diagnose the women who need treatment in this age group.

Long-term follow-up of cervical cancer incidence after normal cytological findings

An increase in cervical cancer incidence in Sweden from 2014 to 2015 has been attributed to an increase in false-negative cytological findings before cancer diagnoses. Years later, we performed a long-term follow-up to investigate whether the problem persisted. At each calendar year from 2016 to 2020, we identified women with prior normal cervical screening results through linkage to the Swedish National Cervical Screening Registry. We reported their incidence rates (IRs) of invasive cervical cancer in consecutive years and compared the IRs over time. For the years 2016 to 2020, there was no overall change in cervical cancer incidence after two normal cytology in the last two screening intervals. However, there was a further 62% increase among women 50 to 60 years of age with normal cytology in the past two screening intervals. The incidence rate of cervical cancer was high among nonscreened women and low among HPV-screened women with negative results, with no trends over time. Our results imply that the previously reported decrease in sensitivity of cervical cytology is persisting. Although primary cytology screening is no longer used, cytology is used in triaging among HPV-positive women. Our findings suggest that improved triaging is needed, for example, improved quality assurance and/or use of alternative triage tests.

Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study

As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages.

Significance

To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.

A cervical screening initiative for elderly women in Denmark

INTRODUCTION

To assess outcome of a one-time human papillomavirus (HPV)-screening in 2017 of Danish women aged 70+.

MATERIAL AND METHODS

Women born 1947 or before were personally invited to have a cell-sample collected by their general practitioner. Screening- and follow-up samples were analyzed in hospital laboratories in the five Danish regions and registered centrally. Follow-up procedures varied slightly across regions. Cervical intraepithelial neoplasia 2 (CIN2) was recommended treatment threshold. Data were retrieved from the Danish Quality Database for Cervical Cancer Screening. We calculated CIN2+ and CIN3+ detection rates per 1000 screened women, and number of biopsies and conizations per detected CIN2+ case. We tabulated annual number of incident cervical cancer cases in Denmark for the years 2009-2020.

RESULTS

In total, 359 763 women were invited of whom 108 585 (30% of invited) were screened; 4479 (4.1% of screened, and 4.3% of screened 70-74 years) tested HPV-positive; of whom 2419 (54% of HPV-positive) were recommended follow-up with colposcopy, biopsy and cervical sampling, and 2060 with cell-sample follow-up. In total, 2888 women had histology; of whom 1237 cone specimen and 1651 biopsy only. Out of 1000 screened women 11 (95% confidence interval [CI]: 11-12) had conization. In total, 579 women had CIN2+; 209 CIN2, 314 CIN3, and 56 cancer. Out of 1000 screened women five (95% CI: 5-6) had CIN2+. Detection rate of CIN2+ was highest in regions where conization was used as part of first-line follow-up. In 2009-2016, number of incident cervical cancers in women aged 70+ in Denmark fluctuated around 64; in 2017 it reached 83 cases; and by 2021 the number had decreased to 50.

CONCLUSIONS

The prevalence of high-risk HPV of 4.3% in women aged 70-74 is in agreement with data from Australia, and the detection of five CIN+2 cases per 1000 screened women is in agreement with data for 65-69 year old women in Norway. Data are thus starting to accumulate on primary HPV-screening of elderly women. The screening resulted in a prevalence peak in incident cervical cancers, and it will therefore take some years before the cancer preventive effect of the screening can be evaluated.

Cervical cancer mortality in Norway according to screening attendance and age

INTRODUCTION

The association between cervical cancer screening and reduction of cervical cancer has been dealt with in much research. However, little has been published on the association between screening and cervical cancer mortality. We assessed cervical cancer deaths according to screening history, histopathology, and age among women in, under, and above screening age.

MATERIAL AND METHODS

In this nationwide, registry-based case-control study from Norway, we included 817 cervical cancer deaths in women diagnosed with cervical cancer in the period 1998-2009. We matched each case with 10 population-based controls free from cervical cancer, obtained by density-based sampling. Odds ratios (ORs) with 95% confidence intervals (CIs) for the association between screening attendance and cervical cancer mortality were estimated using conditional logistic regression models.

RESULTS

Of all fatal cervical cancers, 35% were diagnosed among women over screening age and altogether, 83% were either in age groups not covered by the screening program or in non-attenders of screening age. The estimated risk reduction associated with a cytology test in the preceding 3.5 years was 80% in screening age 25-69 years (OR 0.20; 95% CI 0.16-0.24) with the largest reduction in squamous cell carcinomas (84%) but also a substantial estimated risk reduction of 65% for adenocarcinomas. The associated risk reduction was strongest in women aged 45-69 years, with ORs in the range 0.09-0.18, compared with ORs 0.42-1.35 in women aged 25-39 years.

CONCLUSIONS

To reduce the mortality of cervical cancer, screening programs should focus on increasing adherence to the program, as half of all the fatal cases were in the non-attender group. Further assessments regarding the potential preventive impact of extending screening to women over the current screening age should be considered.

LncRNA ABHD11-AS1 Participates in the Progression of Cervical Carcinoma by Targeting miR-1254 and Is the Key to the Diagnosis and Treatment of Cervical Carcinoma in the Future

Cervical carcinoma is the most common gynecologic tumor in the clinic. The incidence of cervical carcinoma has been increasing in recent years, and the age of the affected population is showing a younger trend. Long-chain noncoding RNA (LncRNA) acts in the cell cycle. In cervical carcinoma, many studies have also confirmed the important role of LncRNA. LncRNA ABHD11-AS1 is one of the genes abnormally expressed in cervical carcinoma, but the specific situation has not been fully explained. This study intended to confirm whether LncRNA ABHD11-AS1 can be applied for the treatment of cervical carcinoma in the future. From January 2015 to January 2017, 72 cases of cervical carcinoma patients and 78 cases of healthy people during the same period in our hospital were selected for prospective analysis. ABHD11-AS1 and miR-1254 in serum and carcinoma tissues of cervical carcinoma patients were detected. In addition, human cervical carcinoma cells HeLa and CaSki were obtained to analyze the effects of interference with ABHD11-AS1 and miR-1254 on the biological behavior of cervical carcinoma cells. Finally, the correlation of ABHD11-AS1 with miR-1254 was verified by double fluorescein reporter enzyme and immunocoprecipitation. ABHD11-AS1 was upregulated, and miR-1254 was reduced in serum and carcinoma tissues of cervical carcinoma patients (P < 0.05). The expression levels of the two were negatively correlated (P < 0.001). ABHD11-AS1 decreased and miR-1254 increased in serum of cervical carcinoma patients after treatment (P < 0.05). High ABHD11-AS1 and low miR-1254 had a close correlation with the poor prognosis of cervical carcinoma patients (P < 0.05). Silencing LncRNA ABHD11-AS1 could inhibit the activity of cervical carcinoma cells (P < 0.05), while inhibiting miR-1254 could promote the activity of cervical carcinoma cells (P < 0.05). ENCORI online website found that LncRNA ABHD11-AS1 and miR-1254 had binding sites. Bifluorescein reporter enzyme experiment found that ABHD11-AS1-WT fluorescence activity was inhibited by transfected miR-1254-mimics (P < 0.05). LncRNA ABHD11-AS1 accelerates proliferation, invasion, and migration of cervical carcinoma cells through targeted regulation of miR-1254, which may become the key to the treatment of cervical carcinoma.

Influence of age on treatment and prognosis of invasive cervical cancer

OBJECTIVE

Invasive cervical cancer is considered a young women's disease, however up to 20 % of cases develop cervical cancer at advanced ages. The aim was to characterize invasive cervical cancer in women aged 65 and older assessing age-specific survival differences.

STUDY DESIGN

A retrospective study including cervical cancer patients was conducted at Hospital del Mar Barcelona from July-2007 to December-2016. Women were stratified: <65 or ≥65years. Clinical and pathological data were collected. Multivariate analysis was used to compare outcomes. Adjusted hazard ratios with 95 % confidence intervals for disease-free survival, and overall survival were estimated using Cox proportional hazards models.

RESULTS

124 patients with invasive cervical cancer (n = 87 < 65years and n = 37 ≥ 65years) were included. At diagnosis, 48.3 % of <65years patients were diagnosed at advanced stages, while 64.9 % in ≥65years (p = 0.018). Standard treatment was given to 83.9 % of patients in <65years group compared to 62.2 % in ≥65years (p = 0.015). Disease-free survival and overall survival showed no significant differences between groups. Age ≥65 did not predict worse disease-free survival (HR: 0.3 95 %CI, 0.04-3.1, p = 0.347) or overall survival (HR: 0.82 95 %CI, 0.3-2.3, p = 0.729).

CONCLUSION

Invasive cervical cancer was diagnosed at advanced stages and was treated less frequently with radical intention in patients ≥65years; overall survival and disease-free survival were similar to those cervical cancer diagnosed at younger ages.

Associations of treated and untreated human papillomavirus infection with preterm delivery and neonatal mortality: A Swedish population-based study

BACKGROUND

Treatment of cervical intraepithelial neoplasia (CIN) is associated with an increased risk of preterm delivery (PTD) although the exact pathomechanism is not yet understood. Women with untreated CIN also seem to have an increased risk of PTD. It is unclear whether this is attributable to human papillomavirus (HPV) infection or other factors. We aimed to investigate whether HPV infection shortly before or during pregnancy, as well as previous treatment for CIN, is associated with an increased risk of PTD and other adverse obstetric and neonatal outcomes.

METHODS AND FINDINGS

This was a retrospective population-based register study of women with singleton deliveries registered in the Swedish Medical Birth Register 1999-2016 (n = 1,044,023). The study population had a mean age of 30.2 years (SD 5.2) and a mean body mass index of 25.4 kg/m2 (SD 3.0), and 44% of the women were nulliparous before delivery. Study groups were defined based on cervical HPV tests, cytology, and histology, as registered in the Swedish National Cervical Screening Registry. Women with a history of exclusively normal cytology (n = 338,109) were compared to women with positive HPV tests (n = 2,550) or abnormal cytology (n = 11,727) within 6 months prior to conception or during the pregnancy, women treated for CIN3 before delivery (n = 23,185), and women with CIN2+ diagnosed after delivery (n = 33,760). Study groups were compared concerning obstetric and neonatal outcomes by logistic regression, and comparisons were adjusted for socioeconomic and health-related confounders. HPV infection was associated with PTD (adjusted odds ratio [aOR] 1.19, 95% CI 1.01-1.42, p = 0.042), preterm prelabor rupture of membranes (pPROM) (aOR 1.52, 95% CI 1.18-1.96, p < 0.001), prelabor rupture of membranes (PROM) (aOR 1.24, 95% CI 1.08-1.42, p = 0.002), and neonatal mortality (aOR 2.69, 95% CI 1.25-5.78, p = 0.011). Treatment for CIN was associated with PTD (aOR 1.85, 95% CI 1.76-1.95, p < 0.001), spontaneous PTD (aOR 2.06, 95% CI 1.95-2.17, p < 0.001), pPROM (aOR 2.36, 95% CI 2.19-2.54, p < 0.001), PROM (aOR 1.11, 95% CI 1.05-1.17, p < 0.001), intrauterine fetal death (aOR 1.35, 95% CI 1.05-1.72, p = 0.019), chorioamnionitis (aOR 2.75, 95% CI 2.33-3.23, p < 0.001), intrapartum fever (aOR 1.24, 95% CI 1.07-1.44, p = 0.003), neonatal sepsis (aOR 1.55, 95% CI 1.37-1.75, p < 0.001), and neonatal mortality (aOR 1.79, 95% CI 1.30-2.45, p < 0.001). Women with CIN2+ diagnosed within 3 years after delivery had increased PTD risk (aOR 1.18, 95% CI 1.10-1.27, p < 0.001). Limitations of the study include the retrospective design and the fact that because HPV test results only became available in 2007, abnormal cytology was used as a proxy for HPV infection.

CONCLUSIONS

In this study, we found that HPV infection shortly before or during pregnancy was associated with PTD, pPROM, PROM, and neonatal mortality. Previous treatment for CIN was associated with even greater risks for PTD and pPROM and was also associated with PROM, neonatal mortality, and maternal and neonatal infectious complications.

Study of the biological function of LncRNA LUCAT1 on cervical cancer cells by targeting miR-199b-5p

To explore the effect and mechanism of LncRNA LUCAT1 in cervical cancer (CC). In the present study, 67 cases of CC patients and 60 healthy cases were selected as the research objects. CC patients were selected as the study group (SG) and healthy physical examination patients were selected as the control group (CG). LUCAT1 expression level in peripheral blood was detected in the two groups. Human cervical carcinoma cells C33A, AV3 and normal cervical epithelial cells H8 were purchased for biological behavior analysis. LUCAT1 was highly expressed in SG and cancer tissues (P<0.050), and it had good diagnostic value for the development of CC (P<0.001). It was closely related to the differentiation, pathological stage and metastasis of CC (P<0.001). The prognosis of CC patients was affected (P<0.050). After transfecting LUCAT1 into CC cells, it was found that the proliferation, invasion ability and anti-apoptosis protein of CC cells were significantly reduced, while the apoptosis rate and apoptosis protein were significantly increased by inhibiting LUCAT1 expression (P<0.050). However, after transfecting miR-199b-5p into CC cells, it was found that the proliferation, invasion ability and anti-apoptosis protein of CC cells were significantly increased, while the apoptosis rate and apoptosis protein were significantly decreased by inhibiting LUCAT1 expression (P<0.050). LUCAT1 was highly expressed in CC. It was involved in the tumor development of CC by targeting miR-199b-5p, which was of great significance for the diagnosis and treatment of CC in the future.

Histological outcomes in HPV-screened elderly women in Denmark

Introduction

Danish women exit cervical cancer screening at age 65 years, but 23% of cervical cancer cases occur beyond this age. In addition, due to gradual implementation of cervical cancer screening, older women are underscreened by today´s standards. A one-time screening with HPV test was therefore offered to Danish women born before 1948.

Methods

Register based study reporting histology diagnoses and conizations in women found HPV positive in the one-time screening. Number and proportion of women with severe or non-severe histology results were calculated for screened and HPV-positive women by age group or region of residence. Number of women with biopsy and/or conization per case of cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+) or CIN3+ were also calculated by age groups and region.

Results

4,479 (4.1% of screened women) had positive HPV test. 94% of these had one or more additional tests. 2,785 (62%) of HPV-positive women had histology results, and conization was performed in 1,076 (24% of HPV-positive and 1% of all screened women). HPV positivity and CIN3+ detection varied little between regions, but the proportions of HPV positive women undergoing histology varied between regions from 40% to 86% and the proportion with conization from 13% to 36%. Correspondingly, the number of histologies and conizations per CIN3+ detected varied from 5.9 to 11.2 and 1.8 to 4.7, respectively. In total, 514 CIN2+ (0.47% of screened women, 11% of HPV-positive) and 337 CIN3+ (0.31% of screened women, 7.5% of HPV-positive) were diagnosed, including 37 cervical cancer cases.

Discussion

HPV screening of insufficiently screened birth cohorts can potentially prevent morbidity and mortality from cervical cancer but longer follow-up is needed to see if cancer incidence declines in the screened women in the coming years. Management strategies differed among regions which influenced the proportions undergoing biopsy/conization.

Expanding the upper age limit for cervical cancer screening: a protocol for a nationwide non-randomised intervention study

INTRODUCTION

Cervical cancer screening ceases between the ages of 60 and 65 in most countries. Yet, a relatively high proportion of cervical cancers are diagnosed in women above the screening age. This study will evaluate if screening of women aged 65-69 years may result in increased detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) compared with women not invited to screening. Invited women may choose between general practitioner (GP)-based screening or cervico-vaginal self-sampling. Furthermore, the study will assess if self-sampling is superior to GP-based screening in reaching long-term unscreened women.

METHODS AND ANALYSIS

This population-based non-randomised intervention study will include 10 000 women aged 65-69 years, with no record of a cervical cytology sample or screening invitation in the 5 years before inclusion. Women who have opted-out of the screening programme or have a record of hysterectomy or cervical amputation are excluded. Women residing in the Central Denmark Region (CDR) are allocated to the intervention group, while women residing in the remaining four Danish regions are allocated to the reference group. The intervention group is invited for human papillomavirus-based screening by attending routine screening at the GP or by requesting a self-sampling kit. The reference group receives standard care which is the opportunity to have a cervical cytology sample obtained at the GP or by a gynaecologist. The study started in April 2019 and will run over the next 4.5 years. The primary outcome will be the proportion of CIN2+ detected in the intervention and reference groups. In the intervention group, the proportion of long-term unscreened women attending GP-based screening or self-sampling will be compared.

ETHICS AND DISSEMINATION

The study has been submitted to the Ethical Committee in the CDR which deemed that the study was not notifiable to the Committee and informed consent is therefore not required. The study is approved by the Danish Data Protection Regulation and the Danish Patient Safety Authority. Results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04114968.

Screening history and FIGO-stages among Danish women with cervical cancer in 2012-2014: a register-based study

The objective was to examine whether attendance in the mass cervical screening programme has implications for the prognosis when cervical cancer is diagnosed. We performed a retrospective analysis of all cases of cervical cancer between 1st of January 2012 and 31st of December 2014 in the Region of Southern Denmark. The cases were retrieved from the Danish National Pathology Registry, PatoBank. Odds ratios (OR) with confidence intervals (95% CI) were calculated for attendees versus non-attendees of the screening programme by using χ2-test. 216 patients were included in the study. 61.6% of the study population had not attended the screening programme. Patients who had attended the programme were characterised by disease in low stage (OR = 3.14, 95% CI; 1.66 to 5.92), treatment with surgery alone (OR = 2.63, 95% CI; 1.49 to 4.64) and a lower risk of death (OR = 0.36, 95% CI; 0.15 to 0.87). Adenocarcinomas were more often detected among attendees of the programme compared to squamous cell carcinomas (OR = 4.06, 95% CI; 2.03 to 8.14). Statistically significant results regarding relapse of cancer (OR = 0.62, 95% CI; 0.23 to 1.68, p = 0.47) and lymph node metastases (OR = 0.62, 95% CI; 0.32 to 1.21, p = 0.19) were not found. Cervical cancer detected in women who had attended the mass cervical screening programme prior to the diagnosis, was shown to have a statistically significant lower FIGO stage (p = 0.0004) and was therefore linked to less extensive treatment options. Continued focus on increasing the participation rate of the programme is of importance, as the nonattendance rate continues to be high.

Effectiveness of cervical cancer screening at age 65 - A register-based cohort study

Most cervical cancer deaths in Finland occur after the termination of the national screening program, targeted at women aged 30 to 64 years. The purpose of this study was to examine the effectiveness of screening at age 65 in reducing cervical cancer mortality. A register-based cohort study was performed with a follow-up period between 1991 and 2014. Mortality risk ratios for incident cervical cancer cases diagnosed at age 65 or older were compared between women invited and not invited for screening. The background risk difference between the studied areas was accounted for by using a reference cohort. The relative risk of death for women invited for cervical cancer screening at the age of 65 was 0.52 (95% CI: 0.29-0.94). The relative risks for women not attending and attending to screening with respect to the uninvited were 1.28 (CI: 0.65-2.50) and 0.28 (CI: 0.13-0.59), respectively. Inviting 65-year-old women for screening has been effective in reducing cervical cancer mortality.

Abnormal cervical cytology is associated with preterm delivery: A population based study

INTRODUCTION

Increasing evidence suggests that cervical intraepithelial neoplasia, with or without subsequent treatment, is associated with preterm delivery. We aimed to explore the association between abnormal cervical cytology of different severity and the subsequent obstetric outcomes such as preterm delivery.

MATERIAL AND METHODS

The historical register-based cohort study comprised 19 822 women in the Western Region of Sweden who had at least one abnormal cervical cytology from 1978 to 2012 before the age of 45 and a subsequent singleton delivery. The reference group comprised 39 644 women with normal cervical cytology and a subsequent singleton delivery, matched by age and parity. Data were retrieved from the Swedish National Cervical Screening Registry, linked to the Swedish Medical Birth Register and Statistic Sweden. The study outcomes were spontaneous preterm delivery before 37 and 34 weeks, low birthweight (≤2500 g), small-for-gestational-age, preterm premature rupture of membranes and neonatal mortality. Multivariable log binominal regression analyses were applied.

RESULTS

Preterm delivery before 37 weeks was more common among women with abnormal cervical cytology compared with reference group: 6% vs 4.5%; adjusted relative risk 1.30 (95% confidence interval 1.21-1.39). High vs low-grade abnormal cervical cytology implied a higher risk: 7% vs 5.8% (P < 0.001). Early preterm delivery before 34 weeks, preterm premature rupture of membranes and low birthweight, but not small-for-gestational-age and neonatal mortality, were significantly more common in women with abnormal cervical cytology compared with the reference group.

CONCLUSIONS

Abnormal cervical cytology may imply an increased risk of preterm delivery. Further studies are needed to investigate whether that risk is related to treatment.

The Situation of Cervical Cancers in the Context of Female Genital Cancer Clustering and Burden of Disease in Arad County, Romania

Romania has the highest incidence of cervical cancer morbidity and mortality in Europe. This study identifies the major clusters for genital cancers, observes the features of genital and cervical cancer, and determines the extent to which cancer is a contributor to total Disability-Adjusted Life Year (DALY). Spatial analysis used Besag and Newell’s method for genital cancer distribution, prevalence considered Arad County patients records (2008–2017), and DALY was determined according to WHO methodology and GLOBOCAN 2013 data. Diagnosis was established by histopathological examination of diagnostic biopsies or tissues obtained by surgical procedures, followed by clinical staging. 1695 women were recorded with genital cancer. Of these, 14.9% of lesions were in situ (n = 252) and 74.20% of cases were recorded in stage III or IV (n = 1258) (p < 0.0001). Over 90% of cervical cancers were squamous cell carcinomas (n = 728), 33.76% of endometrial cancers were adenocarcinomas in situ (n = 131), 32.42% of ovarian cancers were serous adenocarcinomas (n = 131), and 70.58% of vulvar cancers were squamous cell carcinomas (n = 48) (p < 0.0001). DALY/1000 was 67.2 for genital cancers and 33 for cervical cancers. From the point of view of Romanian women, cervical cancer remains one of the major problems that need to be dealt with and access to optimal treatment proves to be extremely limited.

Trends in cervical cancer incidence and survival in Estonia from 1995 to 2014

Background

Cervical cancer (CC) incidence in Estonia is the third highest in Europe, even though an organised nation-wide screening program has been in place since 2006.

The aim of the study was to analyse the incidence and survival of CC in Estonia, focusing on age, morphology and stage at diagnosis.

Methods

Data from Estonian Cancer Registry were used to analyse age-standardized (world) and age-specific incidence for 1968–2014 rates. Joinpoint regression was used to estimate the annual percentage change (APC) for incidence trends. Age-period-cohort model was used to summarise time trends in terms of cohort and period effects. Relative survival ratios (RSR) were calculated for cases diagnosed in 1995–2014. Union for International Cancer Control version 7 of the TNM classification for malignant tumours was used to categorise stage.

Results

The age-standardized incidence of CC increased since 1980s at a rate of 0.8% per year. A significant increase was seen for all age groups except for 70+. The incidence of squamous cell carcinoma mimicked the overall trend, while adenocarcinoma showed increase since mid-1990s (APC 6.7). Age-period-cohort modelling showed strong cohort effects with the lowest risk for birth-cohorts born around 1940 and significantly increasing risks for successive cohorts born thereafter. No period effects were seen.

The proportion of stage IV cases increased from 13% in 2005–2009 to 18% in 2010–2014. A significant increase was seen in the overall 5-year RSR from 1995 to 1999 to 2010–2014 (58% vs 66%). In 2010–2014, the 5-year RSRs ranged from 89% in women aged 15–39 to 41% in age group 70+. For stages I to IV, the respective RSRs were 98, 74, 57 and 22%.

Conclusions

The inadequate uptake and insufficient quality of the Pap-smear based screening program has not brought along a decline in the incidence of CC in Estonia. Stage distribution has shifted towards later stages. New approaches are needed to prevent CC in Estonia.

How confident can we be in the current guidelines for exiting cervical screening?

Current US guidelines recommend against cervical screening beyond age 65 in women who have had adequate negative screening. In anticipation of the next round of evidence review and guideline updates, we provide a critical review of the evidence supporting the exiting recommendation in the US, highlighting both practice changes and new insights into the epidemiology and natural history of HPV and cervical cancer. Current recommendations are based, by necessity, on cytology alone, and will be limited in generalizability to evolving screening strategies with co-testing and primary HPV testing. The lack of empirical data to define what constitutes 'adequate recent screening with negative results' is compounded by difficulties in predicting future risk without consideration of concepts of HPV latency and cohort effects of changing sexual behaviour in US women over time. We urge caution in extrapolating past risk experience in post-menopausal women to today's population, and suggest study designs to strengthen the evidence base in well-screened older women. We further recommend building the qualitative evidence base to better define the harms and benefits of screening among older women. Extending the lifetime of screening is a matter of finding the appropriate balance of benefits of cancer reduction and limitation of harms and costs of 'overscreening'. This will require moving beyond current emphasis on number of colposcopies as the metric of harm. Our commentary is meant to stimulate intellectual debate regarding the certainty of our existing knowledge base and set clear research priorities for the future.

An overview of cervical cancer epidemiology and prevention in Scandinavia

New technologies such as human papillomavirus (HPV) testing and vaccination necessitate comprehensive policy analyses to optimize cervical cancer prevention. To inform future Scandinavian-specific policy analyses, we aimed to provide an overview of cervical cancer epidemiology and existing prevention efforts in Denmark, Norway and Sweden. We compiled and summarized data on current prevention strategies, population demography and epidemiology (for example, age-specific HPV prevalence and cervical cancer incidence over time) for each Scandinavian country by reviewing published literature and official guidelines, performing registry-based analyses using primary data and having discussions with experts in each country. In Scandinavia, opportunistic screening occurred as early as the 1950s and by 1996, all countries had implemented nationwide organized cytology-based screening. Prior to implementation of widespread screening and during 1960-66, cervical cancer incidence was considerably higher in Denmark than in Norway and Sweden. Decades of cytology-based screening later (i.e. 2010-2014), cervical cancer incidence has been considerably reduced and has converged across the countries since the 1960s, although it still remains lowest in Sweden. Generally, Scandinavian countries face similar cervical cancer burdens and utilize similar prevention approaches; however, important differences remain. Future policy analyses will need to evaluate whether these differences warrant differential prevention policies or whether efforts can be streamlined across Scandinavia.

Effectiveness of cervical screening after age 60 years according to screening history: Nationwide cohort study in Sweden

BACKGROUND

The relatively high incidence of cervical cancer in women at older ages is a continuing concern in countries with long-established cervical screening. Controversy remains on when and how to cease screening. Existing population-based studies on the effectiveness of cervical screening at older ages have not considered women's screening history. We performed a nationwide cohort study to investigate the incidence of cervical cancer after age 60 years and its association with cervical screening at age 61-65, stratified by screening history at age 51-60.

METHODS AND FINDINGS

Using the Total Population Register, we identified 569,132 women born between 1 January 1919 and 31 December 1945, resident in Sweden since age 51. Women's cytological screening records, cervical cancer occurrence, and FIGO stage (for those diagnosed with cancer) were retrieved from national registers and medical charts. We calculated the cumulative incidence of cervical cancer from age 61 to age 80 using a survival function considering competing risk, and estimated the hazard ratio (HR) of cervical cancer in relation to screening status at age 61-65 from Cox models, adjusted for birth cohort and level of education, conditioning on women's screening history in their 50s. In women unscreened in their 50s, the cumulative incidence up to age 80 was 5.0 per 1,000 women, and screening at age 61-65 was associated with a lower risk for cervical cancer (HR = 0.42, 95% CI 0.24-0.72), corresponding to a decrease of 3.3 cancer cases per 1,000 women. A higher cumulative incidence and similarly statistically significant risk decrease was seen for women with abnormal smears in their 50s. In women adequately or inadequately screened with only normal results between age 51 and age 60, the cumulative incidence of cervical cancer from age 61 to 80 was 1.6 and 2.5 per 1,000 women, respectively, and further screening at age 61-65 was not associated with statistically significant decreases of cervical cancer risk up to age 80, but with fewer cancer cases of advanced stages at age 61-65. Adjustment for potential lifestyle confounders was limited.

CONCLUSIONS

In this study, cervical screening with cytology at age 61-65 was associated with a statistically significant reduction of subsequent cervical cancer risk for women who were unscreened, or screened with abnormalities, in their 50s. In women screened with normal results in their 50s, the risk for future cancer was not sizeable, and the risk reduction associated with continued screening appeared limited. These findings should inform the current debate regarding age and criteria to discontinue cervical screening.