Cervical cancer screening programmes and policies in 18 European countries

Prevalence and trends of cervical cancer screening among women in Fiji from 2014 to 2018

Introduction

Cervical cancer is the third most common cancer in women both in developed and developing countries. This study aimed to determine the prevalence of cervical cancer and the trends of cervical cancer screening among women who had cervical cancer screening in Suva, Fiji between 2014 and 2018.

Materials and method

This study applied a 5-year retrospective electronic chart review of data from all women attending the Women's Wellness Clinic (WWC) in Suva, Fiji. The women who were selected for this study and screened for cervical cancer were Fijian citizens above 18 years of age and were registered in 2014-2018. A data collection form was used to collect data. The data was analyzed using Statistical Package for Social Sciences (SPSS) version 24; p <0.05 % was considered as the level of significance.

Results

Among the 39,579 women who attended WWC for other family planning services, 12,074 women screened for cervical cancer with a prevalence of 30.5 %. The overall mean age for women screened for cervical cancer was 37.6 (SD ± 11.2). Two-thirds (76.4 %) of the women screened for cervical cancer were less than 46 years of age and 53.9 % were I-taukei. The number of women who came for Pap smear increased in 2015, however, a slight decline was observed in 2016 which was later improved to 35.1 % in 2018. Malignancy was more common in the age range of 42-49 respectively. In this study, women of 46 years and above had an OR of 0.51 (95 % CI: 0.36, 0.72), other ethnicity OR was 1.73 (95 % CI: 1.27, 2.35), and the Muslim religion OR recorded was 1.44 (95 % CI: 1.03, 2.01) which was comparatively considered a high-risk group. Women who are widowed 1.57 (95 % CI: 0.798, 3.11), single 1.29 (95 % CI: 0.87, 1.92) or divorced 1.08 (95 % CI: 0.59, 1.99), employed 1.01 (95 % CI: 0.83, 1.24) and are living in rural areas 1.19 (95 % CI: 0.82, 1.73) are also associated with higher odds of having abnormal results.

Conclusion

Cervical cancer is listed as the first and most common type of cancer in women which is noticeably increasing in Fiji. Even though cervical cancer screening has improved over the years, adequate surveillance systems and ongoing programs should be designed and implemented to increase awareness and monitor the trend of cervical cancer screening in order to reduce cervical cancer prevalence and mortality rates.

An economic evaluation of two cervical screening algorithms in Belgium: HR-HPV primary compared to HR-HPV and liquid-based cytology co-testing

OBJECTIVE

To assess the costs and benefits of two algorithms for cervical cancer screening in Belgium (1) high-risk human papillomavirus (HR-HPV) primary screening and (2) HR-HPV and liquid-based cytology (LBC) co-testing.

METHODS

A decision tree was adapted from published work and parameterised using HORIZON study data and Belgian cost and population data. The theoretical model represents two different screening algorithms for a cohort of 577 846 women aged 25-64 attending routine cervical screening. Scenario analyses were used to explore the impact of including vaccinated women and alternative pricing approaches. Uncertainty analyses were conducted.

RESULTS

The cost per woman screened was €113.50 for HR-HPV primary screening and €101.70 for co-testing, representing a total cost of €65 588 573 and €58 775 083, respectively, for the cohort; a 10% difference. For one screening cycle, compared to HR-HPV primary, co-testing resulted in 13 173 more colposcopies, 67 731 more HR-HPV tests and 477 020 more LBC tests. Co-testing identified 2351 more CIN2+ cases per year (27% more than HR-HPV primary) and 1602 more CIN3+ cases (24% more than HR-HPV primary) than HR-HPV primary.

CONCLUSION

In Belgium, a co-testing algorithm could increase cervical pre-cancer detection rates compared to HR-HPV primary. Co-testing would cost less than HR-HPV primary if the cost of the HPV test and LBC were cost-neutral compared to the current cost of LBC screening but would cost more if the cost per HPV test and LBC were the same in both co-testing and HR-HPV primary strategies.

Population-based cancer registries in Nigeria and the National Cancer Control Programme

Population-based cancer registries (PBCRs) are important sources of data on cancer burden in a defined population. They are a cornerstone for establishing, implementing and monitoring and evaluating a rational cancer control programme. Despite the long history of PBCRs in more developed countries of the world, PBCRs in sub-Saharan Africa are still poorly developed and cancer control is poor. Compared to PBCRs in Europe and the United States, cancer registries in sub-Saharan Africa are still functioning at a basic level. Only a few cancer registries in sub-Saharan Africa contribute data regularly to the International Agency for Cancer Registries' (IACR) GLOBOCAN and Cancer in Five Continents' publication series. In Nigeria, there have been efforts at strengthening existing PBCRs and creating new ones, and implementing national cancer control programmes. It is however unclear how successful these efforts have been. It is therefore necessary to reflect on documented activities so far in order to identify gaps and proffer solutions.

Survival, Incidence, and Mortality Trends in Female Cancers in the Nordic Countries

Background

Female cancers cover common breast cancers, relatively common endometrial, ovarian, and cervical cancers and rare vulvar cancer. Survival in these cancers is known to be relatively good compared to all cancers but long-term studies for these cancers are rare, and to fill the gap, here, we generate survival data through 50 years.

Materials and Methods

We applied generalized additive models to data from the NORDCAN database and analyzed 1- and 5-year relative survival for these cancers in Denmark (DK), Finland (FI), Norway (NO), and Sweden (SE) over half a century (1971-2020). Conditional 5/1-year survival for patients who survived the 1st year after diagnosis and annual survival changes was also estimated.

Results

In 2016-20, 5-year survival was best for breast cancer reaching 92.3% (in SE), followed by endometrial cancer at 86.1% (SE) and cervical cancer at 75.6% (NO). Improvement in 5-year survival over the 50 years was the largest for ovarian cancer (20% units), finally reaching 52.9% (SE). For vulvar cancer, the final survival was between 70 and 73%. The best 5-year survival rate in 2016-20 was recorded for SE in breast, endometrial, and ovarian cancers; NO showed the highest rate for cervical and DK for vulvar cancers. DK had the lowest survival for breast and ovarian cancers, and FI, for the other cancers.

Conclusions

The overall survival development appeared to consist of continuous improvements, most likely because of novel treatment and imaging techniques as well as overall organization of patient care. The large survival improvement for ovarian cancer was probably achieved by a surgical focus on tumors spread in the peritoneal cavity. For cervical and vulvar cancers, the high early mortality requires attention and could be helped by raising increasing public awareness of early symptoms in these cancers and developing pathways for fast initiation of treatment.

Texture Analysis in Uterine Cervix Carcinoma: Primary Tumour and Lymph Node Assessment

The conventional magnetic resonance imaging (MRI) evaluation and staging of cervical cancer encounters several pitfalls, partially due to subjective evaluations of medical images. Fifty-six patients with histologically proven cervical malignancies (squamous cell carcinomas, n = 42; adenocarcinomas, n = 14) who underwent pre-treatment MRI examinations were retrospectively included. The lymph node status (non-metastatic lymph nodes, n = 39; metastatic lymph nodes, n = 17) was assessed using pathological and imaging findings. The texture analysis of primary tumours and lymph nodes was performed on T2-weighted images. Texture parameters with the highest ability to discriminate between the two histological types of primary tumours and metastatic and non-metastatic lymph nodes were selected based on Fisher coefficients (cut-off value > 3). The parameters' discriminative ability was tested using an k nearest neighbour (KNN) classifier, and by comparing their absolute values through an univariate and receiver operating characteristic analysis. Results: The KNN classified metastatic and non-metastatic lymph nodes with 93.75% accuracy. Ten entropy variations were able to identify metastatic lymph nodes (sensitivity: 79.17-88%; specificity: 93.48-97.83%). No parameters exceeded the cut-off value when differentiating between histopathological entities. In conclusion, texture analysis can offer a superior non-invasive characterization of lymph node status, which can improve the staging accuracy of cervical cancers.

Indigenous women's experiences of cervical cancer screening: Incorporating Indigenous ways of knowing into a systematic review and meta-synthesis of qualitative research

Due to historical and contextual factors, cervical cancer is typically detected at a later stage in Indigenous women, and so has higher morbidity and mortality. Increasing participation in cervical cancer screening (CCS) could ameliorate this health inequity by detecting cancer when it is more easily treatable. To understand the perspectives, preferences, and experiences of Indigenous women related to participation in CCS, we conducted a systematic review and meta-synthesis of nine qualitative research studies. To advance decolonised qualitative evidence synthesis approaches, we use a modified version of the Two Row Wampum-Covenant Chain Tradition, a Haudenosaunee two-eyed seeing analytic approach that integrates Western approaches with Indigenous worldviews. Using the metaphor of a network of forest plants, we illustrate the systemic and topical barriers and facilitators to CCS, as reported by Indigenous women. We use this metaphor to reiterate the importance of all levels of change to improve CCS experiences for Indigenous women.

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

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

The Effects of Theory-Based Educational Intervention and WhatsApp Follow-up on Papanicolaou Smear Uptake Among Postnatal Women in Malaysia: Randomized Controlled Trial

Background

Despite the availability and accessibility of free Papanicolaou (Pap) smear as a screening tool for cervical cancer, the uptake of Pap smear in Malaysia has not changed in the last 15 years. Previous studies have shown that the high uptake of Pap smear reduces the mortality rate of patients with cervical cancer. The low uptake of Pap smear is multifactorial, and the problem could be minimized through the use of mobile technologies. Nevertheless, most intervention studies focused on individual factors, while other important aspects such as mobile technologies, especially WhatsApp, have not been investigated yet.

Objective

This study aims to determine the effects of a theory-based educational intervention and WhatsApp follow-up (Pap smear uptake [PSU] intervention) in improving PSU among postnatal women in Seremban, Negeri Sembilan, Malaysia.

Methods

A 2-arm, parallel single-blind cluster randomized controlled trial was conducted among postpartum women from the Seremban district. Twelve health clinics were randomly assigned to the intervention and control groups. At baseline, both groups received a self-administered questionnaire. The intervention group received standard care and PSU intervention delivered by a researcher. This 2-stage intervention module was developed based on Social Cognitive Theory, where the first stage was conducted face-to-face and the second stage included a WhatsApp follow-up. The control group received standard care. Participants were observed immediately and at 4, 8, and 12 weeks after the intervention. The primary endpoint was PSU, whereas the secondary endpoints were knowledge, attitude, and self-efficacy scores for Pap smear screening self-assessed using a Google Forms questionnaire. A generalized mixed model was used to determine the effectiveness of the intervention. All data were analyzed using IBM SPSS (version 25), and P value of .05 was considered statistically significant.

Results

We analyzed 401 women, of whom 76 (response rate: 325/401, 81%) had withdrawn because of the COVID-19 pandemic, with a total of 162 respondents in the intervention group and 163 respondents in the control group. The proportion of Pap smears at the 12-week follow-up was 67.9% (110/162) in the intervention group versus 39.8% (65/163) in the control group (P<.001). Significant differences between the intervention and control groups were found for Pap smear use (F_4,1178; P<.001), knowledge scores (F_4,1172=14.946; P<.001), attitude scores (F_4,1172=24.417; P<.001), and self-efficacy scores (F_1,1172=10.432; P<.001).

Conclusions

This study demonstrated that the PSU intervention is effective in increasing the uptake of Pap smear among postnatal women in Seremban district, Malaysia. This intervention module can be tested in other populations of women.

Trial Registration

Thai Clinical Trials Registry TCTR20200205001; https://www.thaiclinicaltrials.org/show/TCTR20200205001

Cervical, vaginal and vulvar cancer incidence and survival trends in Denmark, Finland, Norway and Sweden with implications to treatment

Background

Incidence of cervical cancer has been reduced by organized screening while for vaginal and vulvar cancers no systematic screening has been implemented. All these cancers are associated with human papilloma virus (HPV) infection. We wanted to analyze incidence trends and relative survival in these cancers with specific questions about the possible covariation of incidence, survival changes coinciding with incidence changes and the role of treatment in survival. We used nationwide cancer registry data for Denmark (DK), Finland (FI), Norway (NO) and Sweden (SE) to address these questions.

Methods

We use the NORDCAN database for the analyses: incidence data were available from 1943 in DK, 1953 in FI and NO and 1960 in SE, through 2016. Survival data were available from 1967 through 2016. World standard population was used in age standardization.

Results

In each country the incidence of cervical cancer declined subsequent to rolling out of screening activities. The attained plateau incidence was lowest at 4/100,000 in FI and highest at 10/100,000 in DK and NO. The incidence of vaginal and vulvar cancer remained relatively constant at about 2/100,000. Relative 1-year survival in cervical cancer improved in all countries from low 80%s to high 80%s in the 50-year period, and 5-year survival improved also but at 20% units lower level. Survival gains were found only in patients diagnosed before age 60 years. Survival in vaginal and vulvar cancer followed the same patterns but at a few % units lower level.

Conclusion

Cervical cancer screening appeared to have reached its limits in the Nordic countries by year 2000. Novel treatments, such as immunotherapy, would be needed to improve survival until HPV vaccination will reach population coverage and boost the global fight against these cancers.

Factors associated with participation in the organized cervical cancer screening program in the greater Paris area (France): An analysis among more than 200,000 women

We aimed to identify the contextual factors associated with participation in the organized Cervical Cancer Screening (CCS) pilot program, which includes specific interventions to reach vulnerable women, in the Greater Paris region. Study population consisted of 231,712 women aged 25-65 years, who were not up to date to their smear test and had been invited to take part in the program from July 2014 to September 2017. Using a multilevel mixed logistic regression with random effects, we investigated the effect of grassroots interventions targeting vulnerable women, healthcare provider accessibility, social environment and municipal policy-related factors. The CCS rate was two times higher in women who had received their first invitation to the program during the study period (32·9%) compared to those who were already invited before the study period (15·3%). In both populations, there were no significant trends in participation with regards to the type of grassroots interventions, level of accessibility of healthcare services or municipal commitment to healthcare. Among women invited previously and aged above 35 increased participation was seen in neighborhoods with low proportion of single women or in less deprived neighborhoods. Our results identified groups of women who participated less in the organized CCS program and suggested that additional interventions targeting the barriers faced by vulnerable women, especially those aged 35-45 years old, are needed.

Health services related factors affecting the pap smear services in Fiji: a qualitative study

BACKGROUND

Cervical cancer is the thirdly vast usual cause of cancer in women, and the second vast majority cause of death among women aged 14 to 44 years, both in developed and developing countries. This paper aims to explore the perception of women and Health Care Workers (HCWs) about health care related factors affecting the Pap smear services among women who are screened in the Women Wellness Centre (WWC) in Suva, Fiji.

METHODS

This study used a qualitative method in July-September 2019 in which women screened for cervical cancer used in-depth interviews whereas HCWs used Focus Group Discussion (FGD) in WWC in Suva, Fiji. This study used purposive maximum variation sampling where participants are selected according to the inclusion and exclusion criteria. Semi-structured open ended questionnaires were used to collect the data among participants. Data coding was done until theoretical saturation was reached. Thematic analysis was used and all the text has been coded, themes were abstracted from the coded text segments.

RESULTS

A total of 20 women screened for cervical cancer and 5 HCWs were present during the duration of the study. Health care system was a factor recognized by both groups to have been a cause for the hindrance of cervical screening. There were 8 themes identified from the study, 3 themes from the women screened for cervical cancer and 5 from HCWs. Nearly all the participants reported about the compromised of cervical cancer screening services delivery because of factors such as lack of equipment and supplies, shortage of staff, long distances to health facilities, turnaround time and delay of results which affect the uptake of cervical cancer screening services.

CONCLUSION

While improvement has been made in the distribution of cervical cancer screening in WWC, a number of barriers and factors affect service uptake and delivery. Investments to be made in order to address the identified barriers such as turnaround time, long distances to health facilities, shortage of supplies and staff in order to improve uptake of cervical cancer screening services.

Worldwide trends in cervical cancer incidence and mortality, with predictions for the next 15 years

BACKGROUND

Cervical cancer is 1 of the most common cancers in females worldwide. Understanding the most recent global patterns and temporal trends of cervical cancer burden might be helpful for its prevention and control.

METHODS

Data on cervical cancer (International Classification of Diseases, Tenth Revision, code C53) incidence and mortality in 2018 were extracted from the GLOBOCAN 2018 database and further analyzed for their correlations with the Human Development Index. Temporal trends were analyzed using the annual percent change with joinpoint analysis among 31 countries with highly qualified data from the Cancer Incidence in Five Continents Plus and World Health Organization mortality databases. Future trends for the next 15 years were predicted using an open-source age-period-cohort model.

RESULTS

Cervical cancer incidence and mortality rates were both negatively correlated with the Human Development Index (r = -0.56 for incidence, r = -0.69 for mortality; P < .001) in cross-sectional analysis, and both remained stable in 12 countries or even decreased in 14 and 18 countries for incidence and mortality, respectively, during the most recent 10 data years. Similar findings were observed for the next 15 years.

CONCLUSIONS

Cervical cancer burden was correlated with socioeconomic development. An overwhelming majority of countries had stable or decreasing trends in incidence and mortality rates, especially in those with effective cervical cancer screening programs and human papillomavirus vaccination.

LAY SUMMARY

The authors investigated the most up-to-date data from official databases released by the International Agency for Research on Cancer and found that cervical cancer incidence and mortality were negatively correlated with socioeconomic development. Among the 31 countries analyzed, most (26 countries were analyzed for incidence, and 30 were analyzed for mortality) had stable or even decreasing temporal trends over the most recent 10 years, especially in those with effective cervical cancer screening programs. In addition, the predicted trends for the next 15 years were basically consistent with the observed trends among most of the analyzed countries (19 countries for incidence and 26 countries for mortality).

A comparative analysis of cervical cancer prevention between Nigeria and Nordic countries that have experienced a decline in cervical cancer incidence

BACKGROUND

A modelling analysis carried out in 2014 suggested that, without cervical cancer screening programmes, the incidence of cervical cancer in Denmark, Finland, Norway and Sweden would have been as high as that in some low- and middle-income countries. We compare programme strategies between Nigeria and these Nordic countries and develop translatable recommendations.

METHODS

A literature review using a systematic approach through Medline, Popline, Global Health, CINAHL PLUS, Cochrane Library, EMBASE, Google Scholar, Africa Wide and WHO databases was conducted.

RESULTS

Fifteen journal articles and two grey literature reports met our criteria. Six descriptive studies from Nigeria noted that services in Nigeria were mainly provided in urban secondary/tertiary facilities and that uptake was low even where screening was free. Trials in Nigeria and Sweden noted that subsidies and free programmes alone did not improve uptake; a Danish trial demonstrated that reminders and invitations issued by general practitioners improved participation.

CONCLUSION

Free screening programmes are important but should also consider incentivisation of treatment when needed and demand creation among health workers. Additionally, effective monitoring and evaluation of programme data are key to improving and maintaining quality. More broadly, we suggest that Nigeria can build success through stakeholder-led implementation of well-defined policies with national consensus to ensure coordination and sustainability.

Comparative cost analysis of cervical cancer screening programme based on molecular detection of HPV in Spain

Background

HPV cervical cancer screening (CCS) must use validated HPV tests based on the molecular detection of either viral mRNA (Aptima HPV Assay—AHPV) or DNA. AHPV has demonstrated the same cross-sectional and longitudinal sensitivity for the detection of HSIL/CIN2+ lesions but with greater specificity than HPV-DNA tests. The study aimed to estimate the total costs of a CCS with a primary HPV test based on the detection of mRNA compared to DNA in women aged 35–65 years for the National Health System.

Methods

A decision-tree-based model to estimate the cost of the CCS until the first colposcopy was designed based on Spanish CCS guidelines. The total cost (€, 2019) for CCS with AHPV or DNA tests (HC2 and Cobas) was calculated, including HPV test, liquid-based cytology (LBC) and colposcopy, for a population of 7,263,529 women aged 35–65 years (assuming 70% coverage). Clinical inputs derived from a literature review were validated by a multidisciplinary expert panel. Data from head-to-head studies between different HPV tests were selected.

Results

The use of AHPV showed reduction of 290,541 (− 35%) and 355,913 (− 40%) LBC compared to HC2 or Cobas, respectively. Furthermore, AHPV avoided 151,699 (− 47%) colposcopies versus HC2 and 151,165 (− 47%) versus Cobas. The total cost of CCS was € 282,747,877 with AHPV, € 322,587,588 with HC2 and € 324,614,490 with Cobas. Therefore, AHPV savings € − 39,839,711 versus HC2 and € − 41,866,613 versus Cobas.

Conclusions

Assuming that 70% of women from 35 to 65 years attend the CCS programme, the cost of screening up to the first colposcopy using AHPV would provide cost savings of up to € 41.9 million versus DNA tests in Spain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01310-8.

Screening test accuracy of portable devices that can be used to perform colposcopy for detecting CIN2+ in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Portable devices that can be used to perform colposcopy may improve cervical cancer screening in low- and middle-income countries (LMIC) where access to colposcopy is limited. The objective of this study was to systematically review the diagnostic test accuracy (DTA) of these devices for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+).

METHODS

In accordance with our protocol (Prospero CRD42018104286), we searched Embase, Medline and the Cochrane Controlled Register of Trials up to 9/2019. We included DTA studies, which investigated portable devices with moderate-to-high optical magnification (≥ 6×) for colposcopy, as described in the manual for Colposcopy and Treatment by the International Agency for Research on Cancer, with a histopathological reference standard. We used the QUADAS-2 tool to assess study quality. We examined results for sensitivity and specificity in paired forest plots, stratified by stages in the clinical pathway. We pooled estimates of test accuracy for the index test, used as an add-on to other tests, using a bivariate random-effect model.

RESULTS

We screened 1737 references and assessed 239 full-text articles for eligibility. Five single-gate DTA studies, including 2693 women, met the inclusion criteria. Studies evaluated two devices (Gynocular™ and Pocket) at different stages of the screening pathway. In three studies, which used the index test in an add-on capacity in 1273 women, we found a pooled sensitivity of 0.79 (95% CI 0.55-0.92) and specificity of 0.83 (95% CI 0.59-0.94). The main sources of bias were partial verification, incorporation and classification bias.

CONCLUSION

Few studies have evaluated portable devices able to perform colposcopy, so their accuracy for the detection of CIN2+ remains uncertain. Future studies should include patient-relevant and long-term outcomes, including missed cases, overtreatment, residual and recurrent disease. To meet the challenge of eliminating cervical cancer in LMIC, methods for visual assessment of the cervix need urgent redress.

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

Cervical Cancer Mortality in East-Central European Countries

Changes that took place in Europe in the early 1990s had an impact on health-associated issues. They were an impulse for the changes in healthcare systems and, consequently, also for the changes in cancer control programmes. Those changes also had an effect on mortality rates due to cervical cancer (CC). Therefore, the aim of this study is to analyse CC mortality trends in east-central Europe after 1990. Data on deaths due to CC were retrieved from the WHO Mortality Database. Trends in east-central European countries between 1990 and 2017 were assessed using Joinpoint Regression Program software. CC mortality decreased in the majority of analysed countries. However, an increase was observed in Latvia and Bulgaria. Despite decreasing mortality in the majority of the analysed countries, significant differences were observed. In order to improve the epidemiological situation, effective early detection programmes for cervical cancer ought to be rearranged and based not only on pap smears but also on molecular methods, as well as on introducing widespread programmes of vaccination against HPV.

Use of the Aptima mRNA high-risk human papillomavirus (HR-HPV) assay compared to a DNA HR-HPV assay in the English cervical screening programme: a decision tree model based economic evaluation

OBJECTIVE

To estimate the impact of using the Aptima messenger RNA (mRNA) high-risk human papilloma virus (HR-HPV) assay versus a DNA HR-HPV assay in a primary HPV cervical screening programme.

DESIGN

One hypothetical cohort followed for 3 years through HPV primary cervical screening.

SETTING

England.

PARTICIPANTS

A hypothetical cohort of women aged 25-65 years tested in the National Health Service (NHS) Cervical Screening Programme (CSP) for first call or routine recall testing.

METHODS

A decision tree parameterised with data from the CSP (2017/18) and the HORIZON study. Uncertainty analyses were conducted using data from the FOCAL and GAST studies, other DNA HPV tests in addition to one-way and probabilistic sensitivity and scenarios analyses, to test the robustness of results.

INTERVENTIONS

Aptima mRNA HR-HPV assay and a DNA HR-HPV assay (cobas 4800 HPV assay).

MAIN OUTCOME MEASURES

Primary: total colposcopies and total costs for the cohort. Secondary: total HPV and cytology tests, number lost to follow-up.

RESULTS

At baseline for a population of 2.25 million women, an estimated £15.4 million (95% credibility intervals (CI) £6.5 to 24.1 million) could be saved and 28 009 (95% CI 27 499 to 28 527) unnecessary colposcopies averted if Aptima mRNA assays are used instead of a DNA assay, with 90 605 fewer unnecessary HR-HPV and 253 477 cytology tests performed. These savings are due to a lower number of HPV positive samples in the mRNA arm. When data from other primary HPV screening trials were compared, results indicated that using the Aptima mRNA assay generated cost savings and reduced testing in every scenario.

CONCLUSION

Using the Aptima mRNA assay versus a DNA assay would almost certainly yield cost savings and reduce unnecessary testing and procedures, benefiting the NHS and women in the CSP.

Assessing Knowledge Sharing in Cancer Screening Among High-, Middle-, and Low-Income Countries: Insights From the International Cancer Screening Network

PURPOSE

As the global burden of cancer rises, global knowledge sharing of effective cancer control practices will be critical. The International Cancer Screening Network (ICSN) of the US National Cancer Institute facilitates knowledge sharing to advance cancer screening research and practice. Our analysis assessed perceptions of ICSN's value and knowledge sharing in cancer screening among participants working in high-income countries (HICs) and low- and middle-income countries (LMICs).

METHODS

In 2018, the National Cancer Institute fielded a self-administered, online survey to 665 ICSN participants from both HICs and LMICs.

RESULTS

Two hundred forty-three individuals (36.5%) completed the full survey. LMIC participants engaged in more diverse screening activities and had fewer years of experience (13.5% with more than 20 years of experience v 31%; P = .048) in screening and were more interested in cervical cancer (76.9% v 52.6%; P = .002) than HIC participants. However, both groups spent most of their time on research (30.8% LMIC v 36.6% HIC; P = .518) and agreed that the ICSN biennial meeting enabled them to learn from the experiences of both higher-resource (88.2% v 75.7%; P = .122) and lower-resource (61.8% v 68.0%; P = .507) settings. ICSN helped them form new collaborations for research and implementation (55.1% v 58.2%; P = .063); informed advances in research/evaluation (71.4% v 68.0%; P = .695), implementation (59.2% v 47.9%; P = .259), and policies in their settings (55.1% v 48.0%; P = .425); and provided the opportunity to contribute their knowledge and expertise to assist others (67.3% v 71.1%; P = .695).

CONCLUSION

Findings suggest that HIC and LMIC participants benefit from knowledge sharing at ICSN meetings although their interests, backgrounds, and needs differ. This points to the importance of international research networks that are inclusive of HIC and LMIC participants in cancer control to advance knowledge and effective practices globally.

The Impact of Triage for Atypical Squamous Cells of Undetermined Significance with Human Papillomavirus Testing in Cervical Cancer Screening in Japan

Background:

One of the features of cervical cancer screening using the combination of cytology and human papillomavirus (HPV) testing is the triage for atypical squamous cells of undetermined significance (ASC-US). The effectiveness of the triage has been recognized widely. However, there are few reports evaluating this triage process in Japan.

Material and Methods:

We retrospectively examined the results of cytology and HPV co-testing for cervical cancer screening in the Oyama area of Tochigi Prefecture between 2012 and 2014. Women who were ASC-US/HPV positive and had cytologic abnormalities [low-grade squamous intraepithelial lesions (LSIL) or worse] were examined by colposcopy. The results of the colposcopy testing were evaluated. In addition, we also examined the results of those who underwent co-testing a year after a ASC-US/HPV-negative result.

Results:

A total of 21,342 women received their first screening test during the study period, with 542 (2.5%) found to have ASC-US. Of the ASC-US-positive women, 289 (53.3%) were also HPV positive. The prevalence of CIN+ (cervical intraepithelial neoplasia or higher) in the ASC-US/HPV-positive group was 63.2%, with 81.8%, 16.4% and 4.8%. showing CIN 1, CIN 2 and CIN 3+, respectively. The prevalence of CIN+ in the LSIL group was 66.8%, with the majority having a low risk CIN 1 (76.6%) compared to CIN 2 (18.6%), and CIN 3+ (4.8%). No significant difference was observed between the LSIL and ASC-US/HPV-positive groups. The prevalence of women diagnosed with CIN in the ASC-US/HPV-negative group, following co-testing a year after colposcopy was low (3%).

Conclusions:

The ASC-US/HPV-positive group was comparable to the LSIL group in terms of prevalence of CIN+ lesions. Furthermore, low CIN prevalence after one year in the ASC-US/HPV-negative group provides confirmation that the screening interval could be extended. The application of HPV triage (which is routine in other countries) to identify these groups would be of benefit in Japan.

What benefits and harms are important for a decision about cervical screening? A study of the perspective of different subgroups of women

Background: In cervical screening programs, women typically receive information leaflets to support their decision about participation. However, these leaflets are often based on what experts consider important benefits and harms of screening and not what women themselves consider important to know. Objective: To identify which benefits and harms women consider important for making a decision about cervical screening. Design: Cross-sectional study. Setting and participants: Women from the Dutch target group of cervical screening (N=248; 30-60 years), recruited through an online access panel. Main variables studied: Perceived importance of different benefits and harms of cervical screening, assessed through two rating items ("How important is the information about [this harm/benefit] for your decision?" and "For me it is a [benefit/harm] that participating in the screening program leads to [the benefit/harm]"), and one ranking item ("Rank the information according to their importance for your own choice"). Results: Women overall considered the benefits of cervical screening more important than the harms or disadvantages. The most important harm according to women was the chance of false positive results (M=4.88; SD=1.75). Differences between those with lower and higher numeracy/health literacy were found regarding several aspects, e.g. for the chance of false positive results, the chance of false negative results, the chance of overtreatment. Discussion and conclusion: The results suggest that leaflets could include more explicit information about false positive results.

Factors Associated with Cervical Cancer Screening among Married Female Immigrants with Korean Husbands in South Korea

Background. The purpose of this study was to identify factors associated with the national cervical cancer screening behaviors of married female immigrants living in South Korea. Methods. The present study dataset was collected by the National Health Insurance Services in 2014–2015. A final study population of 15,935 was considered eligible for inclusion in this study if they met the criteria for participation in the national cervical cancer screening program in 2014–2015. Results. Of the 15,935 subjects, 7837 (49%) participated in cervical cancer screening. Based on the results of the logistic regression analysis of the association between cervical cancer screening behaviors and related factors, the odds ratio (OR) for participation in cervical cancer screening among individuals older than 50 years was the highest (OR: 2.13; 95% confidence interval (CI): 1.82–2.51), and the OR increased as their duration of stay in South Korea decreased. The OR of Chinese women for cervical cancer screening participation was higher than that of non-Chinese women (OR: 1.83; 95% CI: 1.69–1.99). The OR value was 29.4 (95% CI: 25.9–33.3) among those who participated in the general health screening compared with those who did not participate. Conclusions. To improve awareness about cervical cancer screening and reduce disparities in access to healthcare, appropriate programs should be developed to promote cervical cancer screening participation to socially vulnerable classes. Continuous social attention is needed to address these issues and encourage participation in general health screening to improve the rate of cervical cancer screening.

Organized screening programmes for breast and cervical cancer in 17 EU countries: trajectories of attendance rates

BACKGROUND

The aim was to analyse participation trajectories in organised breast and cervical cancer screening programmes and the association between socioeconomic variables and participation.

METHODS

A pooled, cross-sectional, time series analysis was used to evaluate secondary data from 17 European countries in 2004-2014.

RESULTS

The results show that the mammographic screening trend decreases after an initial increase (coefficient for the linear term = 0.40; p = 0.210; 95% CI = - 0.25, 1.06; coefficient for the quadratic term = - 0.07; p = 0.027; 95% CI = - 0.14, - 0.01), while the cervical screening trend is essentially stable (coefficient for the linear term = 0.39, p = 0.312, 95% CI = - 0.42, 1.20; coefficient for the quadratic term = 0.02, p = 0.689, 95% CI = - 0.07, 0.10). There is a significant difference among the country-specific slopes for breast and cervical cancer screening (SD = 16.7, p < 0.001; SD = 14.4, p < 0.001, respectively). No association is found between participation rate and educational level, income, type of employment, unemployment and preventive expenditure. However, participation in cervical cancer screening is significantly associated with a higher proportion of younger women (≤ 49 years) and a higher Gini index (that is, higher income inequality).

CONCLUSIONS

In conclusion three messages: organized cancer screening programmes may reduce the socioeconomic inequalities in younger people's use of preventive services over time; socioeconomic variables are not related to participation rates; these rates do not reach a level of stability in several countries. Therefore, without effective recruitment strategies and tailored organizations, screening participation may not achieve additional gains.

Cervical cancer prevention: An Italian scenario between organised screening and human papillomaviruses vaccination

We aimed to assess the cervical cancer burden and performance of screening programme over the last decade in Apulia, Italy. Data from Hospital Discharge, Causes of Death and of Outpatient Services registries were analysed to estimate the disease burden, and data collected by the screening information system were used to evaluate the performance of the programme. We computed annual hospitalisation, incidence and mortality rates and number of outpatient services prescriptions for the follow-up of preneoplastic/neoplastic lesions. Indicators as proposed by the National Centre for Screening Monitoring were computed to describe the screening performance. Hospitalisation rates declined from 47 in 2001 to 28 per 100,000 in 2014, incidence from 10.3 in 2004 to 6.0 per 100,000 in 2014 and mortality from 1.4 in 2001 to 1.0 per 100,000 in 2010. Prescriptions increased from 3,333 in 2006 to 4,968 in 2010, then decreased to 3,634/year in 2012-2014. Actual extension of screening increased from 10.8% in 2007 to 62% in 2014; compliance with the invitation was 32%/year. In the last decade, we observed a reduction in the cervical cancer burden as early effect of screening implementation.

Determinants of Potentially Unnecessary Cervical Cancer Screenings in American Women

Objectives

To identify factors responsible for potentially clinically unnecessary cervical cancer screenings in women with prior hysterectomy.

Methods

A retrospective cross-sectional study was conducted using the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS). This study targeted adult women and examined whether they received a both a Papanicolaou (Pap) test and undergone a hysterectomy in the last three years. We conducted multivariate analyses, including weighted proportions and odds ratios (ORs), based on the modified BRFSS weighting method (raking). The inclusion criteria were adult women (>18 years old) who reported having received a Pap test within the last 3 years.

Results

Of all women (n=252 391), 72 366 had received a Pap test, and 32 935 of those women (45%, or 12.5 million, weighted) had a prior hysterectomy. We found that age, race/ethnicity, marital status, family income, health status, time since last routine checkup, and health insurance coverage were all significant predictors. Black, non-Hispanic women were 2.23 times more likely to receive Pap testing after a hysterectomy than white women (OR, 2.23; 95% confidence interval [CI], 1.99 to 2.50). Similarly, the odds for Hispanic women were 2.34 times higher (OR, 2.34; 95% CI, 1.97 to 2.80). The odds were also higher for those who were married (OR, 1.17; 95% CI, 1.08 to 1.27), healthier (OR, 1.24; 95% CI, 1.14 to 1.35), and had health insurance (OR, 1.54; 95% CI, 1.28 to 1.84), after controlling for confounders.

Conclusions

We conclude that women may potentially receive Pap tests even if they are not at risk for cervical cancer, and may not be adequately informed about the need for screenings. We recommend strategies to disseminate recommendations and information to patients, their families, and care providers.

Abdominal aortic aneurysm screening attendance: Effect of removing the examination fee

OBJECTIVES

The organized population-based screening programme for abdominal aortic aneurysm in Stockholm, Sweden, started in 2010. An examination fee was initially charged, but later removed because of a policy change. We examined the effect on screening attendance of removing the fee.

METHODS

The periods before and after removing the examination fee were compared with regard to screening attendance, overall, by municipality and by district.

RESULTS

Screening attendance was 79.2% in the period with an examination fee and 79.9% in the period without an examination fee (p = 0.1787), with no significant change in screening attendance between the periods.

CONCLUSIONS

Although removing examination fees has been shown to have a positive impact on attendance in other screening programmes, we did not find this association in our study.

Incidence of Invasive Cervical Cancer and Direct Costs Associated with its Management in Italy

Aim and background

Cervical cancer is the second most common cancer in European women aged 15–44 years. The aim of this study was to estimate the direct cost of managing invasive cervical cancer in Italy.

Methods

Data from the Italian Network of Cancer Registries were used to estimate the annual number of new cervical cancer cases. To assess the management costs, a typical management pathway for each FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) cervical cancer stage was derived from published guidelines. Data from the Modena Cancer Registry were used to estimate the proportion of patients by FIGO stage. This algorithm was combined with tariffs for outpatient and inpatient procedures to obtain a mean cost for each FIGO stage.

Results

An estimated 2,927 new cases of cervical cancer occurred in Italy in 2005 (crude incidence 9.7/100,000; world age-standardized incidence 6.0/100,000). The estimated numbers of new cases by FIGO stage were: FIGO I, 1,927; FIGO II, 556; FIGO III, 259; and FIGO IV, 185. Costs for the most frequent procedures were estimated as: € 6,041 for radical hysterectomy or other surgery; € 4,901 for radio-chemotherapy; € 1,588 for brachytherapy; and € 3,795 for palliative chemotherapy. Mean management costs for incident cases (including 10 years of follow-up) were estimated at: FIGO I, € 6,024; FIGO II, € 10,572; FIGO III, € 11,367; FIGO IV, € 8707; and € 5,854 for the terminal phase (1 month). The total direct management cost was estimated at € 28.3 million per year.

Conclusions

This is one of the first studies to estimate the direct cost of treating patients newly diagnosed with invasive cervical cancer in Italy. Although according to current management pathways real treatment costs are likely to be underestimated, this information is necessary to design evidence-based vaccination policies able to harmonize primary and secondary prevention of cervical cancer.

Impact of Implementing a Nationwide Cervical Cancer Screening Program on Female Population Coverage by Pap-Tests in Estonia

Background

The objective of the EUROCHIP project in Estonia was to describe the organized cervical cancer screening program started in 2006 (after pilot studies in 2003–2005), to compare its performance with opportunistic screening, and to define priorities for improvement of the program.

Methods

Population data was retrieved from Statistics Estonia, data about performed Pap-smear tests within the screening program from the Estonian Cancer Society and from clinics and labs participating in the program, data about Pap-smear tests outside the screening program from the Estonian Health Insurance Fund, and data about cancer incidence and mortality from the Estonian Cancer Registry database.

Results

During the first year after implementing the nationwide cervical cancer screening program in Estonia, the number of tests outside the organized program remained high. Within the organized program, the number of Pap-tests in different age groups increased with age except for the oldest age group while population coverage with Pap-tests outside the organized screening program decreased with age. The number of cervical cancer cases at early stages increased after implementation of organized screening. The time-frame does not permit to draw any definitive conclusions.

Conclusions

Implementation of organized cervical cancer screening did not decrease the volume of opportunistic screening. The factors influencing attendance in the organized cervical cancer screening program in different age groups should be studied further. Moreover, a central cancer screening registry without restrictive data protection legislation would improve data collection and enable to evaluate performance of the program on a regular basis.

The Incidence and Mortality of Cervical Cancer in Ningbo during 2006-2014, China

BACKGROUND

The purpose of this study was to investigate the incidence and mortality rates of cervical cancer during 2006-2014 in Ningbo, China.

METHODS

A retrospective study involved 3418 newly diagnosed cervical cancer cases and 854 death cases were performed. All cases were registered in Cancer Registry Center of Ningbo Centers for Disease Control and Prevention. Results were expressed as standardized age-specific cancer incidence/mortality rates with confidence intervals. All P-values presented were two-sided and the statistical significance was set at P<0.05.

RESULTS

The crude incidence rate was 34.35 per 100000 in females aged 50-54 years. Females aged 80-84 years had the highest crude mortality rates, which were 12.91 per 100000. The average age-standardized incidence and mortality rates by Chinese Standard Population were 6.29 and 1.49 per 100000, respectively. The average age-standardized incidence and mortality rates by World Standard Population were 8.02 and 1.91 per 100000, respectively. The incidence trend graph showed that annual percent change (APC) increased rapidly by 30.2% (P<0.01) during 2006-2014, while the mortality trend graph indicated a rapid increase in mortality annually by 8.8% (P<0.01) during 2006-2014.

CONCLUSION

We observed an increased trend for both incidence and mortality rates of cervical cancer in Ningbo during 2006 to 2014, which indicated the urgent need for free regular screening for high-risk populations by the government.

Cytology versus HPV testing for cervical cancer screening in the general population

BACKGROUND

Cervical cancer screening has traditionally been based on cervical cytology. Given the aetiological relationship between human papillomavirus (HPV) infection and cervical carcinogenesis, HPV testing has been proposed as an alternative screening test.

OBJECTIVES

To determine the diagnostic accuracy of HPV testing for detecting histologically confirmed cervical intraepithelial neoplasias (CIN) of grade 2 or worse (CIN 2+), including adenocarcinoma in situ, in women participating in primary cervical cancer screening; and how it compares to the accuracy of cytological testing (liquid-based and conventional) at various thresholds.

SEARCH METHODS

We performed a systematic literature search of articles in MEDLINE and Embase (1992 to November 2015) containing quantitative data and handsearched the reference lists of retrieved articles.

SELECTION CRITERIA

We included comparative test accuracy studies if all women received both HPV testing and cervical cytology followed by verification of the disease status with the reference standard, if positive for at least one screening test. The studies had to include women participating in a cervical cancer screening programme who were not being followed up for previous cytological abnormalities.

DATA COLLECTION AND ANALYSIS

We completed a 2 x 2 table with the number of true positives (TP), false positives (FP), true negatives (TN), and false negatives for each screening test (HPV test and cytology) used in each study. We calculated the absolute and relative sensitivities and the specificities of the tests for the detection of CIN 2+ and CIN 3+ at various thresholds and computed sensitivity (TP/(TP + TN) and specificity (TN/ (TN + FP) for each test separately. Relative sensitivity and specificity of one test compared to another test were defined as sensitivity of test-1 over sensitivity of test-2 and specificity of test-1 over specificity of test-2, respectively. To assess bias in the studies, we used the Quality Assessment of Diagnostic test Accuracy Studies (QUADAS) tool. We used a bivariate random-effects model for computing pooled accuracy estimates. This model takes into account the within- and between-study variability and the intrinsic correlation between sensitivity and specificity.

MAIN RESULTS

We included a total of 40 studies in the review, with more than 140,000 women aged between 20 and 70 years old. Many studies were at low risk of bias. There were a sufficient number of included studies with adequate methodology to perform the following test comparisons: hybrid capture 2 (HC2) (1 pg/mL threshold) versus conventional cytology (CC) (atypical squamous cells of undetermined significance (ASCUS)+ and low-grade squamous intraepithelial lesions (LSIL)+ thresholds) or liquid-based cytology (LBC) (ASCUS+ and LSIL+ thresholds), other high-risk HPV tests versus conventional cytology (ASCUS+ and LSIL+ thresholds) or LBC (ASCUS+ and LSIL+ thresholds). For CIN 2+, pooled sensitivity estimates for HC2, CC and LBC (ASCUS+) were 89.9%, 62.5% and 72.9%, respectively, and pooled specificity estimates were 89.9%, 96.6%, and 90.3%, respectively. The results did not differ by age of women (less than or greater than 30 years old), or in studies with verification bias. Accuracy of HC2 was, however, greater in European countries compared to other countries. The results for the sensitivity of the tests were heterogeneous ranging from 52% to 94% for LBC, and 61% to 100% for HC2. Overall, the quality of the evidence for the sensitivity of the tests was moderate, and high for the specificity.The relative sensitivity of HC2 versus CC for CIN 2+ was 1.52 (95% CI: 1.24 to 1.86) and the relative specificity 0.94 (95% CI: 0.92 to 0.96), and versus LBC for CIN 2+ was 1.18 (95% CI: 1.10 to 1.26) and the relative specificity 0.96 (95% CI: 0.95 to 0.97). The relative sensitivity of HC2 versus CC for CIN 3+ was 1.46 (95% CI: 1.12 to 1.91) and the relative specificity 0.95 (95% CI: 0.93 to 0.97). The relative sensitivity of HC2 versus LBC for CIN 3+ was 1.17 (95% CI: 1.07 to 1.28) and the relative specificity 0.96 (95% CI: 0.95 to 0.97).

AUTHORS' CONCLUSIONS

Whilst HPV tests are less likely to miss cases of CIN 2+ and CIN 3+, these tests do lead to more unnecessary referrals. However, a negative HPV test is more reassuring than a negative cytological test, as the cytological test has a greater chance of being falsely negative, which could lead to delays in receiving the appropriate treatment. Evidence from prospective longitudinal studies is needed to establish the relative clinical implications of these tests.

Urgent need to strengthen and expand screening and other cancer control programs in the CARICOM Caribbean

PURPOSE

With high mortality in breast, cervical, prostate, and colorectal cancers in Caribbean Community (CARICOM) countries, we examined cancer control initiatives including screening as well as the implementation of relevant international and regional mandates.

METHODS

Secondary data were used to examine cancer control initiatives, which included the presence of national policies, programs, and screening services as well as the implementation of international and regional mandates. To identify the data, an on-line search was conducted using Google/Google Scholar.

RESULTS

Data were available for 14 of the 15 full members of CARICOM. Although only six countries had distinct cancer control policies, strategies or action plans, all 14 had key elements of cancer control programs. Screening services were available in the 14 countries for cervical, in 12 countries for breast and in 11 for colorectal cancer. However, only four countries had screening policies. In addition, screening guidelines were available for cervical cancer in nine countries, in one country for breast and in none for colorectal cancer. Selected tobacco control policies were present in the 14 countries and immunization policies for human papillomavirus (HPV) in 13. Treatment services included chemotherapy in 10 countries and radiotherapy in six. Nine countries had palliative care services for patients with advanced disease. The countries were at different stages of implementation/compliance with international and regional mandates and frameworks.

CONCLUSIONS

There is an urgent need to develop and implement comprehensive and customized cancer control policies addressing screening programs, treatment and palliative care.

Factors associated with participation in cervical cancer screening among young Koreans: a nationwide cross-sectional study

OBJECTIVES

Despite the possibility of early detection of cervical cancer, participation in screening programmes among young Koreans is low. We sought to identify associations between risk factors and participation in screening for cervical cancer among young Koreans.

DESIGN

Nationwide cross-sectional study.

SETTING

Republic of Korea.

PARTICIPANTS

3734.

MAIN OUTCOME MEASURES

The Korea National Health and Nutrition Examination Survey (KNHANES V: 2010-2012) was used to evaluate factors associated with attendance for cervical cancer screening among women aged 15-39. After excluding those who were previously diagnosed with cervical cancer and those with incomplete responses to questionnaires, a total of 3734 subjects were eligible. Multi-dimensional covariates as potential predictors of cervical cancer screening were adjusted in multiple logistic regression analysis.

RESULTS

The participation rate for cervical cancer screening was 46% among women aged 40 or younger. The logistic analyses showed that age, education, total household income, smoking and job status among women aged 15-39 were associated with participation in cervical cancer screening (p<0.05). After age stratification, the associated factors differed by age groups. Moreover, a dose-response between participation in cervical cancer screening and high total household income in the 30-39 age group was seen.

CONCLUSIONS

Predictive factors differed among young women (aged 15-29 vs 30-39). Thus, age-specific tailored interventions and policies are needed to increase the participation rate in screening for cervical cancer.

Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities

Background: Incidence and mortality of cervical cancer declined thanks to Pap smear screening. However cervical cancer screening (CCS) inequalities are documented, including in high income countries. This population-based study aims to assess the importance and 20-year trends of CCS inequalities in Switzerland, where healthcare costs and medical coverage are among the highest in the world. Methods: We analyzed data from five waves of the population-based Swiss Health Interview Survey (SHIS) covering the period 1992–2012. Multivariable Poisson regression were used to estimate weighted prevalence ratios (PR) of CCS and 95% Confidence Intervals (CI) adjusting for socio-economic, socio-demographic characteristics, family status, health status, and use of healthcare. Results: The study included 32’651 women aged between 20 and 70 years old. Between 1992 and 2012, rates of CCS over the past 3 years fluctuated between 71.7 and 79.6% (adjusted P < 0.001). Lower CCS was observed among women with low education, low income, those having limited emotional support, who were non-Swiss, single, older, living in non-metropolitan area or in the French-speaking region, overweight. Over the analyzed period, differences in CCS across age groups diminished while rates among women who visited a GP over the previous year, versus those who did not, increased. Conclusions : While important changes occurred in screening recommendations and in social circumstances of the targeted population, CCS rates remained fairly stable in Switzerland between 1992 and 2012. At the same time, inequalities in CCS persisted over that period.

A Population-based Study of Invasive Cervical Cancer Patients in Beijing: 1993-2008

BACKGROUND

In recent years, the incidence of cervical cancer has been rising, particularly in young adults, as the second most common gynecological cancer in China. The aim of this study was to explore the incidence change and the epidemiological characteristics of cervical cancer in Beijing over the past 16 years.

METHODS

All the cases of the study were limited to Beijing residents diagnosed with cervical cancer and registered in Beijing from January 1, 1993, to December 31, 2008. A total of 4100 patients with cervical cancer were obtained from the Statistics Database of Beijing Cancer Registry (BJCaR). According to the registered data, we retrospectively reviewed all original cases which we can acquired in reported hospital. Cervical situ cancer, cervical metastatic cancer, non-Beijing residents and repeatedly registered cases were excluded. Totally, 3641 registered cases were verified correctly. Meanwhile, we also collected the following data: Age, occupation, detected methods, histological type, and staging. The trends of incidence and mortality were analyzed by Joinpoint Regression Program 4.1.1.1 produced by National Cancer Institute (NCI, USA). The annual percent change (APC) was calculated using the Joinpoint regression model.

RESULTS

The crude rates of incidence and mortality were 10.4 and 1.0 per 100,000 women, respectively during 1993 to 2008. The average WHO age-standardized incidence rates were 11.5 per 100,000 women. There was a decrease in incidence annually by 8.0% (P = 0.3) during 1993-1996 and a rapid increase annually by 18.9% after 1999 (P < 0.01). The median age was 67 years in 1993, but the median age decreased to 45 years in 2008. The peak of the age-specific incidence curve was at 40 years in the most recent period (2005-2008), which was 25-30 years earlier than that in previous periods (1993-1996). In the 2224 cases, the numbers of patients with stage I, II, III and IV were 910 (40.9%), 601 (27%), 542 (24.4%), 171 (7.7%), respectively. The percentage of patients with stage I was 7.6% (13/171) in 1993-1996, but the percentage increased to 51.6% (643/1247) in 2005-2008 (P < 0.01). Otherwise the percentage of advanced stage (stage III-IV) during the same period was dropped down significantly from 52.0% (89/171) to 22.5% (280/1247) (P < 0.01). Unemployed and housewife ranked first accounting for 27.3% of the total (607/2224). Urban low-income people such as worker ranked the second accounting for 17.0% (377/2224), the third place was farmer accounting for 14.0% (312/2224). Only 381 (17.1%, 381/2224) women in 2224 were first detected cervical cancer by routine screenings. Company staff (36.5%, 139/381), professional and technical personnel (22.6%, 86/381), national official (22.0%, 84/381) occupied the top three (total 81.1%) in the 381 patients detected cervical cancer by screening.

CONCLUSIONS

The cervical cancer incidence has showed a continuous rise in Beijing since 1999. Government-led mass screening should target the low socioeconomic population primarily. Meanwhile the government should enhance public health education of cancer screening to increase the rate of screening.

Interventions to encourage uptake of cancer screening for people with severe mental illness

BACKGROUND

Adults with severe mental illness (i.e. schizophrenia or other related psychotic disorders and bipolar disorder) can be at greater risk of cancer than those without severe mental illness (SMI). Early detection of cancer through screening is effective in improving patient outcomes including death. However, people with SMI are less likely than others to take up available cancer screening.

OBJECTIVES

To determine the effectiveness of interventions targeted at adults with SMI, or their carers or health professionals, and aimed at increasing the uptake of cancer screening tests for which the adults with SMI are eligible.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (October 25, 2012; December 19, 2014; April 07, 2015; July 04, 2016).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of interventions, targeted towards adults with SMI or their carers or health professionals, to encourage uptake of cancer screening tests for which the adults with SMI were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and assessed these against the inclusion criteria.

MAIN RESULTS

We did not find any trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

A comprehensive search showed that currently there is no RCT evidence for any method of encouraging cancer screening uptake in people with SMI. No specific approach can therefore be recommended. High-quality, large-scale RCTs are needed urgently to help address the disparity between people with SMI and others in cancer screening uptake.

Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer

OBJECTIVE

Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC.

METHODS

We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results.

RESULTS

We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran.

CONCLUSION

We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.

Engaging Canadian First Nations Women in Cervical Screening through Education

Recognition of the need to decrease cervical cancer rates in Indigenous populations has been ongoing-yet few successful interventions have been reported. In addition, literature addressing the challenges and barriers associated with designing screening programs aimed to specifically reach Indigenous women is limited. Here, we report findings from a mixed methods cervical cancer research project conducted in partnership with 10 First Nations communities in northwest Ontario, Canada. Individual interviews with community health professionals (the majority of whom identified as First Nations) stressed that awareness of cervical screening benefits is lacking. In contrast, focus group participants (women with no formal health education) emphasized the desire to learn more about the science of human papillomavirus (HPV), and that a positive HPV or abnormal Papanicolaou test need not mean a woman will undoubtedly develop cervical cancer. Both the health professionals and the focus group participants highlighted that sexual health education must start early, in schools, preferably before girls are sexually active and that it has to continue throughout life to create a screening culture with a focus on women's wellbeing. Both interview and focus group participants highlighted that sexual health education must start early, in schools, preferably before girls are sexually active and that it has to continue throughout life to create a screening culture with a focus on women's wellbeing. Health professionals elaborated mainly on special events for community women whereas focus group participants also recognized the need to include community men in health education particularly for de-stigmatizing the sexually-transmitted HPV infection.

The genetics and screening of familial hypercholesterolaemia

Familial Hypercholesterolaemia is an autosomal, dominant genetic disorder that leads to elevated blood cholesterol and a dramatically increased risk of atherosclerosis. It is perceived as a rare condition. However it affects 1 in 250 of the population globally, making it an important public health concern. In communities with founder effects, higher disease prevalences are observed.

We discuss the genetic basis of familial hypercholesterolaemia, examining the distribution of variants known to be associated with the condition across the exons of the genes LDLR, ApoB, PCSK9 and LDLRAP1. We also discuss screening programmes for familial hypercholesterolaemia and their cost-effectiveness. Diagnosis typically occurs using one of the Dutch Lipid Clinic Network (DCLN), Simon Broome Register (SBR) or Make Early Diagnosis to Prevent Early Death (MEDPED) criteria, each of which requires a different set of patient data. New cases can be identified by screening the family members of an index case that has been identified as a result of referral to a lipid clinic in a process called cascade screening. Alternatively, universal screening may be used whereby a population is systematically screened.

It is currently significantly more cost effective to identify familial hypercholesterolaemia cases through cascade screening than universal screening. However, the cost of sequencing patient DNA has fallen dramatically in recent years and if the rate of progress continues, this may change.

Survey of Participation in Organised Cervical Cancer-Screening Programme in Hungary

AIM

Cervical cancer mortality is high in Hungary, with more than 400 deaths per annum. In 2003, a national cervical cancer screening programme was launched to provide screening services for women who otherwise would not use services themselves. The aim of this survey was to study the socioeconomic and lifestyle factors related to participation in the organised cervical cancer screening programme.

METHODS

A questionnaire-based health survey was conducted using a representative sample of women from 25-65 years of age in 11 Hungarian counties. A logistic regression analysis was used to study the association between participation in the screening programme and socioeconomic and lifestyle factors.

RESULTS

74% (95% CI: 70-77%) of the target population underwent a screening examination within the previous three years. Only 15% (95% CI: 5-35%) of the women, who received an invitation letter and took part in the organised screening programme, had never been previously examined by gynaecologist. The participation rates decreased significantly (p<0.05) for those subjects aged >44 years, retired, participants with low income, living in small settlements, and reported to be heavy smokers.

CONCLUSION

Although the overall proportion of Hungary's population that undergoes regular screening for cervical cancer is not low, the organised national cancer screening programme was ineffective in engaging women not regularly visiting their gynaecologist for examination.

Cervical carcinoma in the European Union: an update on disease burden, screening program state of activation, and coverage as of March 2014. Int J Gynecol Cancer. 2015;25:474-483. [PMID: 25695550 DOI: 10.1097/igc.0000000000000374]

OBJECTIVE

Cervical cancer (CC) is defined as a disease of disparity. This is due to marked differences in CC incidence and mortality between developed and developing countries. As a continent, Europe is no exception. This study examines the state of activation of CC screening in the European Union as of March 2014, reviews CC incidence and mortality data, and highlights the initiatives adopted to extend program coverage to nonresponders.

METHODS

The present study is based on the most recent data available from PubMed-indexed journals, the Web sites of the health ministries of each member state, and the Web sites of national cancer observatories; failing these sources, information was sought in scientific journals published in the local language.

RESULTS

In 2003, the European Council recommended that priority be given to organized screening program activation. Nonetheless, a number of European Union member states still lack population-based organized screening programs, and few have implemented programs directed at disadvantaged populations.

CONCLUSIONS

Several investigations have demonstrated that the women at higher CC risk are unscreened and underscreened ones. Since then, several member states have made significant efforts to set up effective prevention programs by adopting international quality standards and centralizing screening organization and result evaluation. Several developed countries and some new central-eastern European member states have poorly organized prevention programs that result in poor women's health. Diagnosis of CC is emotionally traumatic, but it is highly preventable. When CC is found early, it is highly treatable and associated with long survival and good quality of life.

Effectiveness of three interventions in improving adherence to cervical cancer screening

In countries where cervical cancer screening programmes are conducted on an opportunistic basis, an active search for women at risk should be made to increase coverage. The objective of our study was to assess the effectiveness of three primary care interventions consisting of providing written, telephone and face-to-face information to increase screening participation among women over the age of 25 years. A randomized experimental study with only one post-test control group was conducted on women aged 25-70 years. A total of 1676 women were randomly distributed into four groups and the following interventions were implemented: written briefing; telephone briefing; an invitation to attend a group meeting and no briefing (control group). The women were evaluated 2 years after the intervention. The outcome variable was participation or nonparticipation in cervical cancer screening. It proved possible to interview a total of 1122 women. Among the groups, homogeneity was tested in terms of sociodemographic characteristics and health-related variables. Women who had undergone cytological testing in the 2 years preceding evaluation had a lower mean age (P<0.001) than women who had not done so (45.5±11.0 vs. 48.8±13.0 years). The proportion of women who had participated in screening was as follows: 35.3% in the written information group [95% confidence interval (CI) 29.8-40.9]; 38.4% in the telephone information group (95% CI 32.5-44.2); 29.3% in the face-to-face information group (95% CI 22.8-35.7) and 26.1% in the control group (95% CI 21.2-30.9), with this difference proving statistically significant (P=0.005). Logistic regression showed that only the interventions based on written or telephone briefing were effective vis-à-vis the control group. In conclusion, both written and telephone information can serve to improve women's participation in opportunistic cervical cancer screening. Current preventive strategies could be optimized by means of simple interventions within the scope of health professionals.

Diagnostic performance of diffusion-weighted MRI for detection of pelvic metastatic lymph nodes in patients with cervical cancer: a systematic review and meta-analysis

In recent years, diffusion-weighted (DW) MRI has emerged as a new technique for detecting the pelvic lymph metastases in patients with cervical cancer. The aim of this meta-analysis was to assess the diagnostic value of DW imaging (DWI) for benign/malignant discrimination of pelvic lymph nodes (LNs). Studies about DWI for the detection of metastatic LNs were searched in the PubMed, EMBASE, Web of Science, EBSCO, the Cochrane Library and three Chinese databases. Based on the extracted data, we determined pooled sensitivities, specificities and diagnostic odds ratios (DORs) across studies, calculated positive and negative likelihood ratios (LRs) and constructed summary receiver operating characteristic curves with area under the curve (AUC) and Q* obtained. We also analysed the heterogeneity between studies based on subgroup analysis, threshold effect and publication bias. In total, 15 studies involving 1021 patients met the inclusion criteria. The pooled sensitivity, specificity and DOR of DWI were 0.86 [95% confidence interval (CI), 0.84-0.89], 0.84 (95% CI, 0.83-0.86) and 47.21 (95% CI, 25.67-86.81), respectively. LR syntheses yielded overall positive LR of 6.55 (95% CI, 4.77-9.01) and negative LR of 0.17 (95% CI, 0.12-0.23). The AUC and Q* index were 0.9384 and 0.8754, respectively. The heterogeneity was relatively high between studies; however, there was no evidence for threshold effect and publication bias. DWI is beneficial in the pelvic nodal assessment in patients with cervical cancer. Large-scale, high-quality trials with standard protocols are required to evaluate its clinical value for discrimination of metastatic from non-metastatic pelvic LNs in patients with cervical cancer. Advances in knowledge include providing evidence to assess the role of DWI in nodal staging of cervical cancer.

Early diagnosis behavior in Turkish women with and without a family history of cervical cancer

BACKGROUND

This study was planned as comparative and descriptive in order to measure and evaluate the knowledge and attitudes regarding early diagnosis of women with and without a family history of cervical cancer.

MATERIALS AND METHODS

The study sample consisted of the relatives of female patients (N=253) who were admitted to Istanbul University of Medicine. Women with a family history of cervical cancer formed the case group, while those without family history of cervical cancer constituted the control group. Two distinct data collection tools, a questionnaire and the Miller Behavioral Style Scale (MBSS), were used in order to obtain data for evaluation with SPSS for Windows 20.0 statistics package program.

RESULTS

It was found that 61.0% of the case group with family history of cervical cancer and 19.0% of the control group without family history of cervical cancer were using early diagnostic methods. Thus the presence of an individual with cervical cancer in the family affected the attitudes towards early diagnosis. It was further found that the level of knowledge on cervical cancer and PAP smear test was higher in the case group, which was more sensitive with regard to being informed about cervical cancer as compared to general society. However, the average MBSS scores were not significantly different compared to the control group.

CONCLUSIONS

It was noted that, women participating this study knowledgeable, but this did not necessarily transform into better behavior.