Investigating the decrease in participation in the Dutch cervical cancer screening programme: The role of personal and organisational characteristics

Accuracy of real-time PCR assays for human papillomavirus using urine samples: a systematic review and meta-analysis

This study aims to assess the diagnostic accuracy of real-time PCR assays for detecting human papillomavirus (HPV) in urine samples through a systematic review and meta-analysis. A comprehensive search of PubMed, Embase, and Springer databases (2014-2024) was conducted. Studies comparing urine-based HPV tests with cervical samples as the reference standard were included. Diagnostic accuracy measures such as sensitivity, specificity, diagnostic odds ratio (DOR), likelihood ratios (LR+ and LR-), percent agreement, and Cohen's kappa were calculated. Heterogeneity was assessed using the Higgins' I² index, and subgroup analyses were performed based on HPV test type and urine volume. The study revealed that 15 studies met the inclusion criteria, with pooled sensitivity of urine-based HPV tests at 0.82 (95% CI, 0.78-0.86), specificity at 0.91 (95% CI, 0.87-0.94), positive LR at 9.5 (95% CI, 6.3-14.3), negative LR at 0.19 (95% CI, 0.16-0.24), DOR at 49 (95% CI, 32-75), and the area under the curve at 0.92 (95% CI, 0.90-0.94), with significant heterogeneity observed (I² >50%), particularly in sensitivity and specificity, and subgroup analysis indicating that urine volumes ≤20 mL demonstrated higher sensitivity compared to those >20 mL, despite this finding being based on a limited number of studies. Results suggest that urine-based HPV testing shows strong diagnostic accuracy and could be a viable alternative to cervical swabs, with potential benefits for increasing screening accessibility, especially in areas with limited healthcare resources, despite some variability and limitations in the data.IMPORTANCEThis study is significant as it thoroughly evaluates the diagnostic accuracy of real-time PCR assays for human papillomavirus (HPV) detection in urine samples through a rigorous systematic review and meta-analysis. By integrating data from multiple databases and comparing urine-based HPV tests with the established cervical sample reference standard, the study provides valuable insights into the effectiveness and reliability of non-invasive HPV screening methods. The findings demonstrate that urine-based tests exhibit high sensitivity and specificity, offering a promising alternative to traditional cervical swabs. This advancement has significant implications for increasing accessibility to HPV screening, particularly in under-resourced settings, thereby potentially enhancing cervical cancer prevention efforts on a broader scale. The study not only fills a critical gap in HPV screening methodologies but also supports the development of more inclusive and practical public health strategies for combating cervical cancer.

Influencing factors on attendance in cervical cancer screening among women with diabetes in Hungary: a cross-sectional study using European Health Interview Surveys 2009-2019

Introduction

With this study, we examined the participation in cervical cancer screening among women with diabetes and the influencing factors of attendance.

Methods

Data from the European Health Interview Surveys in Hungary (2009, 2014, 2019) were analyzed with multivariate and multiple logistic regressions.

Results

A higher level of education (OR=2.56, 95% CI: 1.03-6.33 in the case of secondary level in 2014; and OR=3.09, 95% CI: 1.17-8.13 in the case of tertiary level in 2019, OR= 2.24, 95% CI: 1.12-4.46 in the case of tertiary level in the pooled data), a perceived good economic situation (OR=2.31, 95% CI: 1.30-4.09 in the pooled data), participation in breast cancer screening (OR= 5.41, 95% CI: 3.49-8.38 in the pooled data), and social support (OR= 2.04 95% CI: 1.03-4.03 in 2019) have a positive effect on participation in screening. Taking prescription drugs (OR= 0.31 95% CI: 0.12-0.83, in the pooled data), lower economic status (OR=0.25 95% CI:0.07-0.88, in 2009) and worse perceived health (OR= 0.20, 95% CI: 0.06-0.64 in 2014) can be considered factors with a negative effect.

Conclusion

This study identified groups with low participation rates and made it clear that those groups with unfavorable health factors (bad financial status, bad perceived health, taking prescription drugs) participate the least in screening.

Evidence from Europe on implementation, participation and performance of self-collection for cervical cancer screening

Cervical cancer screening programs reduce the number of cervical cancer cases and deaths, but the success of any screening program is dependent on high participant uptake and coverage and many European countries are observing declining cervical cancer screening coverage to below national targets. Self-collection of vaginal samples for human papillomavirus testing, also termed self-sampling, is one strategy which is being introduced to try to increase screening coverage by removing barriers to participation and it has attracted growing interest and support globally. Informed by peer-reviewed and gray literature, this narrative review starts with a case study from the Netherlands and outlines the self-collection landscape in Europe within the themes of program implementation and relative test performance. It highlights some of the current evidence gaps needed to inform policy decisions on the use of self-collection within screening programs.

Experiences and Perceptions of Cervical Cancer Screening Using Self-Sampling among Under-Screened Women in Flanders

Primary Human Papillomavirus (HPV) screening on samples collected by women themselves has proven to be an effective strategy for cervical cancer screening (CCS) and may increase participation rates in women who do not partake (regularly) in screening. The aim of this study is to investigate reasons for non-participation and perceptions of CCS using self-sampling methods among under-screened women in Flanders. Individual interviews with 15 underscreened women aged 30-64 years were conducted. During the interviews, participants were given the opportunity to try out a urine and vaginal self-sampling kit. Thematic analysis was based on Ajzen's model of the Theory of Planned Behavior. The results showed that 14 out of 15 participants were more likely to participate in CCS if they had the option to self-sample. One of the main findings was a lack of knowledge on different aspects of cervical cancer. Most women had a positive attitude toward cancer screening and primary prevention such as HPV vaccination. Subjective norms were influenced by healthcare professionals, peers, and organized government initiatives. Informational, organizational, contextual, and emotional factors were mentioned as barriers as well as facilitators for participation. Additionally, high self-efficacy was considered to make self-sampling more convenient. All women showed the intention to use at least one method of self-sampling. We can conclude that women who do not participate in CCS would be more motivated to participate using self-sampling methods. Adequate education and guidance should be provided.

Public health nurse perspectives on predicting nonattendance for cervical cancer screening through classification, ensemble, and deep learning models

OBJECTIVES

Women's attendance to cervical cancer screening (CCS) is a major concern for healthcare providers in community. This study aims to use the various algorithms that can accurately predict the most barriers of women for nonattendance to CS.

DESIGN

The real-time data were collected from women presented at OPD of primary health centers (PHCs). About 1046 women's data regarding attendance and nonattendance to CCS were included. In this study, we have used three models, classification, ensemble, and deep learning models, to compare the specific accuracy and AU-ROC for predicting non-attenders for CC.

RESULTS

The current model employs 22 predictors, with soft voting in ensemble models showing slightly higher specificity (96%) and sensitivity (93%) than weighted averaging. Bagging excels with the highest accuracy (98.49%), specificity (97.3%), and ideal sensitivity (100%) with an AUC of 0.99. Classification models reveal Naive Bayes with higher specificity (97%) but lower sensitivity (91%) than Logistic Regression. Random Forest and Neural Network achieve the highest accuracy (98.49%), with an AUC of 0.98. In deep learning, LSTM has an accuracy of 95.68%, higher specificity (97.60%), and lower sensitivity (93.42%) compared to other models. MLP and NN showed the highest AUC values of 0.99.

CONCLUSION

Employing ensemble and deep learning models proved most effective in predicting barriers to nonattendance in cervical screening.

Impact of health-related behavioral factors on participation in a cervical cancer screening program: the lifelines population-based cohort

BACKGROUND

Regular participation in cervical cancer screening is critical to reducing mortality. Although certain sociodemographic factors are known to be associated with one-time participation in screening, little is known about other factors that could be related to regular participation. Therefore, this study evaluated the association between health-related behavioral factors and regular participation in cervical cancer screening.

METHODS

The Lifelines population-based cohort was linked to data for cervical cancer screening from the Dutch Nationwide Pathology Databank. We included women eligible for all four screening rounds between 2000 and 2019, classifying them as regular (4 attendances), irregular (1-3 attendances), and never participants. Multinomial logistic regression was performed to evaluate the association between behavioral factors and participation regularity, with adjustment made for sociodemographic factors.

RESULTS

Of the 48,325 included women, 55.9%, 35.1%, and 9% were regular, irregular, and never screening participants. After adjustment for sociodemographic factors, the likelihood of irregular or never screening participation was increased by smoking, obesity, marginal or inadequate sleep duration, alcohol consumption and low physical activity, while it was decreased by hormonal contraception use.

CONCLUSION

An association exists between unhealthy behavioral factors and never or irregular participation in cervical cancer screening.

Sociodemographic Characteristics and Screening Outcomes of Women Preferring Self-Sampling in the Dutch Cervical Cancer Screening Programme: A Population-Based Study

BACKGROUND

In the Netherlands, lower high-risk human papillomavirus (hrHPV) positivity but higher cervical intraepithelial neoplasia (CIN) 2+ detection were found in self-collected compared with clinician-collected samples. To investigate the possible reason for these differences, we compared sociodemographic and screening characteristics of women and related these to screening outcomes.

METHODS

We extracted data from PALGA on all primary hrHPV screens and associated follow-up tests for 857,866 screened women, invited in 2017 and 2018. We linked these data with sociodemographic data from Statistics Netherlands. Logistic regression was performed for hrHPV positivity and CIN 2+/3+ detection.

RESULTS

Out of the 857,866 women, 6.8% chose to use a self-sampling device. A higher proportion of self-sampling users was ages 30 to 35 years, was not previously screened, was living in a one-person household, or was the breadwinner in the household. After adjustment for these factors self-sampling had lower hrHPV positivity (aOR, 0.65; 95% CI, 0.63-0.68)) as compared with clinician-collected sampling, as well as lower odds of CIN 2+ (aOR, 0.76; 95% CI, 0.70-0.82) and CIN 3+ (aOR, 0.86; 95% CI, 0.78-0.95) detection.

CONCLUSIONS

It is likely that the observed differences between the two sampling methods are not only related to sociodemographic differences, but related to differences in screening test accuracy and/or background risk.

IMPACT

Self-sampling can be used for targeting underscreened women, as a more convenient screening tool. Further investigation is required to evaluate how to implement self-sampling, when it is used as a primary instrument in routine screening. See related commentary by Arbyn et al., p. 159.

Organized Breast and Cervical Cancer Screening: Attendance and Determinants in Rural China

To evaluate the attendance and determinants of organized cervical and breast cancer (two-cancer) screening, especially higher-level factors, we conducted a cross-sectional survey in central China from June 2018 to November 2019 among 1949 women (age ≥ 35 years). We examined organizer-level factors, provider-level factors, receiver-lever factors and attendance and participation willingness of screening. The results indicate that the attendance and participation willingness of organized two-cancer screening was 61.19% and 77.15%, respectively. After adjustment for potential confounders, women who received screening notification were more likely to have greater participation willingness and higher attendance than those who received no notification (adjusted odds ratio [aOR] = 1.59, 95% confidence interval [CI]: 1.27-1.99; aOR = 98.03, 95% CI: 51.44-186.82, respectively). Compared with being notified about screening by GPs, being notified by community women's leaders and other community leaders were more likely to lead to greater willingness to participate again (aOR = 2.86, 95% CI: 1.13-7.24; aOR = 3.27, 95% CI: 1.26-8.48, respectively) and recommending screening to others (aOR = 2.18, 95% CI: 1.02-4.65; aOR = 4.14, 95% CI: 1.84-9.30, respectively). The results suggest that notification of women about screening by community leaders is an important organizer-level factor. As a part of public health services, the design and implementation of optimal cancer screening strategies may require public-sector involvement at the organizer level instead of a one-man show by the health sector.

Experiences and preferences towards collecting a urine and cervicovaginal self-sample among women attending a colposcopy clinic

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In a colposcopy referral population, the majority of women consider self-collection of a urine sample and a cervicovaginal self-sample acceptable and easy to collect in a home-based setting.

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Urine collection is worth investigating as a potential screening method to possibly improve attendance rates in cervical cancer screening.

The effectiveness of cervical cancer screening is hampered by low attendance rates. The collection of a urine sample is hypothesized to engage non-attenders in cervical cancer screening. The aim of this prospective cohort study was to evaluate experiences of women on urine collection and cervicovaginal self-sampling in a home-based setting and preferences for future cervical cancer screening. This study included 140 women, with a median age of 40 years, who were planned for a large loop excision of the transformation zone (LLETZ) procedure. All women collected a urine sample using conventional urine cups and a cervicovaginal self-sample prior to the LLETZ in a home-based setting. Following sample collection, women filled in a questionnaire. Results showed that the instructions of urine collection and cervicovaginal self-sampling were considered clear (95%, 95%CI: 88–98; 92%, 95%CI: 83–96, respectively). Women considered urine collection compared to cervicovaginal self-sampling to be more acceptable (p < 0.001), and to provide more reliable results (p < 0.001). The three highest reported preferred sampling methods for future cervical cancer screening were: urine collection (n = 39, 28%, 95%CI: 19–39), clinician-taken cervical scrape (n = 32, 23%, 95%CI: 15–34), and equal preference for urine collection, clinician-taken cervical scrape and cervicovaginal self-sampling (n = 30, 21%, 95%CI: 14–32). In conclusion, urine collection and cervicovaginal self-sampling are acceptable sampling methods, considered easy to collect in a home-based setting, and moreover, considered trustworthy. Although these results are promising, more research is required to determine if urine collection also lowers the barrier for non-attendees and, thereby, increases the attendance rates of cervical cancer screening.