The Japanese Guideline for Cervical Cancer Screening

Are HPV-negative lesions concerned for the introduction of primary HPV testing for cervical cancer screening in Japan?

AIM

In Japan, primary human papilloma virus (HPV) testing has not been introduced for cervical cancer screening due to concerns that HPV-negative lesions may be missed and a lack of Japanese data. The purpose of this study was to evaluate the validity of primary HPV testing in Japan by analyzing cervical intraepithelial neoplasia 2 (CIN2) or more/high-risk HPV- (CIN2+/hrHPV-) cases in cervical cancer screening.

METHODS

Data from 35 525 cervical cancer screenings with HPV testing and cervical cytology from 2011 to 2019 in Saga City, Japan, were reviewed. The cases with low-grade squamous intraepithelial lesion (LSIL+)/hrHPV- were analyzed in detail.

RESULTS

The results of the 35 525 examinees were as follows: 31 123 were negative for intraepithelial lesion or malignancy (NILM)/hrHPV-, 2612 were NILM/hrHPV+, 262 were atypical squamous cells of undetermined significance (ASC-US)/hrHPV-, 213 were ASC-US/hrHPV+, 291 were LSIL+/hrHPV-, and 1024 were LSIL+/hrHPV+. Of the 256 LSIL+/hrHPV- examinees for whom histology was available, CIN2+ were CIN2 9.4% (24/256), CIN3 3.9% (10/256), cervical adenocarcinoma 0.4% (1/256), uterine corpus cancer 1.2% (3/256), and uterine sarcoma 0.4% (1/256). Overall, the rate of LSIL+/hrHPV- was 0.82% (291/35.525), 0.1% (36/35525) of which were cervical lesions with CIN2+. Only one cervical adenocarcinoma was detected, but gastric-type adenocarcinoma was not included.

CONCLUSION

HPV-negative CIN2+ or cervical adenocarcinoma is not a concern for the introduction of primary HPV screening in Japan. Primary HPV testing in cervical cancer screening is considered a feasible method that can be used in Japan, although an algorithm suitable for Japan and a national-level management system need to be established.

Validation of an on-chip p16ink4a/Ki-67 dual immunostaining cervical cytology system using microfluidic device technology

More specific screening systems for cervical cancer may become necessary as the human papillomavirus (HPV) vaccine becomes more widespread. Although p16/Ki-67 dual-staining cytology has several advantages, it requires advanced diagnostic skills. Here, we developed an automated on-chip immunostaining method using a microfluidic device. An electroactive microwell array (EMA) microfluidic device with patterned thin-film electrodes at the bottom of each microwell was used for single-cell capture by dielectrophoresis. Immunostaining and dual staining for p16/Ki-67 were performed on diagnosed liquid cytology samples using the EMA device. The numbers of p16/Ki-67 dual-stained cells captured by the EMA device were determined and compared among the cervical intraepithelial neoplasia (CIN) lesion samples. Seven normal, fifteen CIN grade 3, and seven CIN grade 2 samples were examined. The percentage of dual-positive cells was 18.6% in the CIN grade 2 samples and 23.6% in the CIN grade 3 samples. The percentages of dual-positive staining increased significantly as the severity of the cervical lesions increased. p16/Ki67 dual immunostaining using the EMA device is as sensitive as the conventional method of confirming the histopathological diagnosis of cervical samples. This system enables a quantified parallel analysis at the individual cell level.

Attitudes toward cancer screening in regional Japan during the COVID-19 pandemic: An anonymous survey

The coronavirus disease (COVID-19) pandemic has raised concerns about the impact of delayed health check-ups and cancer screenings on cancer diagnosis and treatment. This study aimed to investigate the awareness of cancer patients on future screening measures during the pandemic in rural Japan. An anonymized open-data survey was undertaken in Fukui Prefecture, a rural region of Japan, in 2021. Participants were asked about their cancer screening history, screening frequency during the pandemic, and reasons for not undergoing screening. Among the 1262 respondents, the proportion of patients who underwent cancer screening in 2020 during the pandemic was similar to the proportion who underwent regular (annual or biannual) screening in 2019 before the pandemic. Of those who underwent regular screening, 82% still underwent screening in 2020, while only 21% of those who had irregular screenings. The number of respondents who believed they were healthy and did not require screening increased over time, possibly due to restrictions on going out and refraining from activities during the pandemic. This study in rural Japan found that regular cancer screening prior to the pandemic was associated with a more positive attitude toward screening during the pandemic. Raising awareness about the importance of cancer screening and encouraging participation is crucial for promoting positive attitudes in the future. The findings highlight the need for continued efforts to ensure access to screening services during the pandemic and future public health emergencies.

Process of developing a cervical cancer education program for female university students in a Health and Physical Education teacher training course: an action research

BACKGROUND

The purpose of this study was to develop a cervical cancer education program for students and evaluate the process for female students of an HPE teacher education university who were training to become Japanese Health and Physical Education teachers.

METHODS

This study used Action Research (AR) methodology. In developing program, we analyzed the description of the teaching material development process, the lectures, and the students' report contents, which was the main activity in the program development. Thirty five third- and fourth-year students majoring in health promotion at a Health and Physical Education teacher education university, which trains Health and Physical Education teachers in Tokyo, Japan, participated in this study.

RESULTS

After a review of the prototype version of the cervical cancer education material, six out of nine reviewers determined that it can be published. In the revised cervical cancer education materials, messages from students, university lecturers, and gynecologists have been added as a column in the section on 'how to prevent cervical cancer. Analysis of the contents of the texts (16,792 characters in total) of 35 student reports resulted in the generation of 51 codes, 3 categories, and 15 subcategories.

CONCLUSIONS

This study reflects the intentions of female university students to contribute their knowledge to the development of educational materials on cervical cancer, which, alongside the lectures, have deepened the knowledge and awareness of cervical cancer. Based on this, the teaching material development process, lectures by experts, and students' mindset after learning about cervical cancer is reported in this study. There is a need for more educational programs on cervical cancer that are implemented through the education of female university students.

Cancer‑associated gene analysis of cervical cytology samples and liquid‑based cytology significantly improve endometrial cancer diagnosis sensitivity

To the best of our knowledge, there are no useful screening methods for early detection of endometrial cancer in asymptomatic individuals. The present study evaluated the usefulness of genetic analysis of liquid-based cytology (LBC) specimens by assessing whether pathological genetic mutations detected in cancer tissue sections were detected in LBC specimens from the cervix and uterus. The primary endpoint was genetic analysis of cervical cytology specimens and LBC for the detection of endometrial cancer. Endometrial thickening (>11 mm) assessed using transvaginal ultrasonography was present in 60% of cases and adenocarcinoma assessed using cervical cytology was present in 50% of cases. In 70% of cases, pathogenic mutations detected in cancer tissue sections were also detected in cervical and/or endometrial LBC specimens. The pathogenic variants identified were PTEN in four cases, tumor protein P53, PI3K catalytic subunit α and fibroblast growth factor receptor 2 in two cases each and APC regulator of WNT signaling pathway, KRAS and catenin β1 in one case each. In the present study, a combination of endometrial thickening assessed by transvaginal ultrasonography, cervical cytology and genetic analysis resulted in a high sensitivity of 90% for detection of endometrial cancer. The combination of these tests is more expensive than conventional methods, but delayed detection of uterine cancer requires multidisciplinary treatment, which increases healthcare costs. Increased spending on early detection of uterine cancer is better economically and may improve patient quality of life.

Cervical cancer screening guidelines and screening practices in 11 countries: A systematic literature review

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Screening guidelines and practices are heterogenous across 11 countries researched.

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Differences persist between screening guidelines and practices within countries.

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Only 6 of 11 countries here examined have national screening registries in place.

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Robust data infrastructure is essential to evaluate screening performance.

The World Health Organization (WHO) advocates population-based screening programs to reduce the global incidence of cervical cancer. However, screening guidelines and practice continually change to reflect scientific developments. Here we describe and compare cervical cancer screening guidelines and clinical practice in 11 countries across North America, Europe, and Asia-Pacific. We conducted a systematic literature review (SLR) complemented by a targeted literature review (TLR) to identify relevant peer-reviewed publications and policy documents, which include 120 publications, of which 86 were identified from the SLR and 34 from the TLR. Only six of 11 countries assessed have population-based screening programs in place. Considerable differences persist across countries’ screening guidelines, even among comparable systems. Moreover, methods of data collection are also heterogenous, and systematic data collection is often not established. As future changes in screening guidelines and clinical practice occur (e.g., when the first cohorts of women vaccinated against HPV reach screening age), systematic collection of screening data is essential to monitor and improve screening performance.

A Deep Learning Model for Cervical Cancer Screening on Liquid-Based Cytology Specimens in Whole Slide Images

Simple Summary

In this pilot study, we aimed to investigate the use of deep learning for the classification of whole-slide images of liquid-based cytology specimens into neoplastic and non-neoplastic. To do so, we used a large training and test sets. Overall, the model achieved good classification performance in classifying whole-slide images, demonstrating the promising potential use of such models for aiding the screening processes for cervical cancer.

Abstract

Liquid-based cytology (LBC) for cervical cancer screening is now more common than the conventional smears, which when digitised from glass slides into whole-slide images (WSIs), opens up the possibility of artificial intelligence (AI)-based automated image analysis. Since conventional screening processes by cytoscreeners and cytopathologists using microscopes is limited in terms of human resources, it is important to develop new computational techniques that can automatically and rapidly diagnose a large amount of specimens without delay, which would be of great benefit for clinical laboratories and hospitals. The goal of this study was to investigate the use of a deep learning model for the classification of WSIs of LBC specimens into neoplastic and non-neoplastic. To do so, we used a dataset of 1605 cervical WSIs. We evaluated the model on three test sets with a combined total of 1468 WSIs, achieving ROC AUCs for WSI diagnosis in the range of 0.89–0.96, demonstrating the promising potential use of such models for aiding screening processes.

Comparative accuracy of cervical cancer screening strategies in healthy asymptomatic women: a systematic review and network meta-analysis

To compare all available accuracy data on screening strategies for identifying cervical intraepithelial neoplasia grade ≥ 2 in healthy asymptomatic women, we performed a systematic review and network meta-analysis. MEDLINE and EMBASE were searched up to October 2020 for paired-design studies of cytology and testing for high-risk genotypes of human papillomavirus (hrHPV). The methods used included a duplicate assessment of eligibility, double extraction of quantitative data, validity assessment, random-effects network meta-analysis of test accuracy, and GRADE rating. Twenty-seven prospective studies (185,269 subjects) were included. The combination of cytology (atypical squamous cells of undetermined significance or higher grades) and hrHPV testing (excepting genotyping for HPV 16 or 18 [HPV16/18]) with the either-positive criterion (OR rule) was the most sensitive/least specific, whereas the same combination with the both-positive criterion (AND rule) was the most specific/least sensitive. Compared with standalone cytology, non-HPV16/18 hrHPV assays were more sensitive/less specific. Two algorithms proposed for primary cytological testing or primary hrHPV testing were ranked in the middle as more sensitive/less specific than standalone cytology and the AND rule combinations but more specific/less sensitive than standalone hrHPV testing and the OR rule combination. Further research is needed to assess these results in population-relevant outcomes at the program level.

Does Direct-to-Consumer Personal Genetic Testing Improve Gynecological Cancer Screening Uptake among Never-Screened Attendees? A Randomized Controlled Study

The clinical impact of direct-to-consumer genetic testing (DTC-GT) on health behavior change has remained controversial. The aim of this study is to clarify the short-term effects of DTC-GT on gynecological cancer screening uptake among middle-aged never-screened Japanese women in a randomized controlled trial (RCT). A total of 144 women aged 45-50 who had never undergone gynecological cancer screening were randomly selected to receive health education (control group), or health education and DTC-GT (intervention group), at a 1:1 ratio. We compared the gynecological screening uptake during the follow-up period. Furthermore, to estimate the impact of learning of an elevated genetic cancer risk in the intervention group, we conducted an analysis dichotomized by genetic risk category. A total of 139 women completed the one-year follow-up survey (69 in the control group and 70 in the intervention group). The follow-up period did not differ between control and intervention groups (the median follow-up period was 276 days and 279 days, respectively, p = 0.746). There were 7 (9.7%) women in the control group and 10 (13.9%) in the intervention group who attended breast cancer screening (p = 0.606), and 9 (12.5%) women from both groups attended cervical cancer screening (p = 1.000). Likewise, there were no significant differences in cancer screening uptake in the analysis stratified by risk category within the intervention group. In conclusion, there was no significant effect of DTC-GT on gynecological cancer screening uptake in this RCT setting. Increasing cancer screening attendance may require a combination of well-established intervention strategies and DTC-GT. Clinical Trial Registration: UMIN-CTR Identifier, UMIN000031709.

International comparison of trends in cancer mortality: Japan has fallen behind in screening-related cancers

While the age-standardized mortality rate in Japan is decreasing for all cancers as a whole, this is not the case for some major site-specific cancers. We descriptively compared trends in all-cancer and site-specific cancer mortality in Japan and selected countries. Data on age-standardized cancer mortality rates in six countries (Japan, the USA, the UK, Canada, Australia and the Republic of Korea) in 1980-2016 were obtained from the World Health Organization mortality database. While stomach and liver cancer mortality rates in Japan and Korea were initially much higher than those in non-Asian countries, they have rapidly decreased over the long term. By contrast, colorectal, pancreatic and cervical cancer mortality rates in Japan, which were initially lower than those in other countries, have increased such that they are now similar or higher than the rates in non-Asian countries. For male lung cancer, Japan's initially lower mortality rate is now comparable to that in non-Asian countries as a result of slower decline. Meanwhile, the mortality rate of female breast cancer in Japan and Korea has increased and is nearing the rates observed in non-Asian countries, which by contrast have shown a steady decrease. Thus, while Japan has been successful in reducing the burden of stomach and liver cancers, it is falling behind in reducing the mortality rate of screening-related cancers such as colorectal, female breast and cervical cancers. Control measures for these cancers need to be strengthened.

Quantifying the Effects of Medical Examination and Possible Risk Factors against the Incidence of Cervical Cancer in a Low Human Papillomavirus Vaccination Coverage: An Ecological Study in Japan

Cervical cancer (CC) is one of the most common gynecological malignancies in females, mainly caused by human papillomavirus (HPV). In countries with lower HPV vaccine coverage, such as Japan, medical examination may play a key role in decreasing CC incidence. This study aimed to quantify the effect of medical examination on cervical cancer (CC) incidence in Japan, considering the effects of possible risk factors. By collecting Japan's Prefectural data on CC incidence (2013-2017), incidence of sexually transmitted diseases (STDs; Chlamydia, Herpes, Condyloma, and Gonorrhea; 1993-2012), screening and detailed examination rate against CC (2013-2016), smoking rate (2001-2013), economic status (disposable income and economic surplus; 2014-2015), and education status (2015), we analyzed associations among them using Pearson's correlation coefficients. Additionally, assuming that the incidence of STDs reflects the frequency of risky sexual behavior at the co-infection point with HPV, we constructed generalized linear models to predict CC incidence, taking a 5-20-year time-lag between incidences of STDs and the CC incidence. Against CC incidence, Chlamydia in females and Gonorrhea in males with a 15-year time-lag showed positive associations, while Condyloma in both genders with a 15-year time-lag, screening rate, economic status, and smoking rate showed negative associations. An increase in screening test rate by 10% was estimated to decrease CC incidence by 9.6%. This means that screening tests decrease CC incidence effectively, but not drastically, suggesting the need for additional countermeasures for CC prevention.

What is the current status of Japan's efforts to meet global goals and targets to eliminate cervical cancer?

Following the global call to action by the World Health Organization (WHO), the world is currently moving to eliminate cervical cancer as a public health problem. To eliminate the cancer within this century, which is defined as an age-adjusted cervical cancer incidence rate (ASIR) below 4 per 100,000 women, WHO recommends all countries to achieve "90-70-90" targets for human papilloma virus (HPV) vaccination, cervical cancer screening, and treatment of precancer and cancer by 2030. In Japan, ASIR has been rising since the late 1990s to 11.1 per 100,000 women, and this rise is particularly prominent in women of reproductive age. HPV vaccination coverage is as low as 0.3%, largely due to the Governments ongoing suspension of proactive recommendations for the vaccine. Given the absence of centralized, population-based cervical cancer screening program and a nationwide surveillance system for systematic monitoring, the exact screening participation rate and treatment rate are difficult to estimate. A national survey suggested that only around 40% of women between the ages of 20 and 69 years underwent cervical cancer screening within the last two years. National policies and systems for HPV vaccination and screening should be updated in a more efficient way as new evidence and innovations become available. In the wake of powerful global momentum, actions must be taken now to further enhance cervical cancer control and ensure that Japanese girls and women are no longer left behind.

Alleviating psychological distress associated with a positive cervical cancer screening result: a randomized control trial

Background

The method of communicating a positive cancer screening result should seek to alleviate psychological distress associated with a positive result. We evaluated whether the provision of information through a leaflet would help reduce psychological distress in a randomized controlled trial.

Methods

The participants were women aged 20–69 years who were about to undergo cervical cancer screening at health centers. Before the screening, they received hypothetical screening results, with a leaflet (intervention group, n = 493) or without it (control group, n = 479), randomly. Their psychological distress and intention to undergo further examination were then compared between the intervention and control groups.

Results

After the intervention (providing a leaflet with hypothetical screening results), psychological distress appeared to be higher in the control group than in the intervention group among those who received a hypothetical positive screening result (odds ratio: 2.57, 95% confidence interval: 1.87–3.54), while 95% and 97% of those in the intervention and control groups, respectively, reported that they would undergo further examination.

Conclusions

Information provision might help reduce psychological distress but not hinder further examination among women who screen positive for cervical cancer.

Trial registration: UMIN Clinical Trials Registry UMIN000029894. Date of Registration: November 2017.

The first-round results of a population-based cohort study of HPV testing in Japanese cervical cancer screening: baseline characteristics, screening results, and referral rate

Objective

In 2013, a cohort study aimed to clarify the positive and negative effects of introducing the human papillomavirus (HPV) testing for population-based cervical cancer screening has been launched in Japan. This study included four screenings during the subsequent 7-year follow-up period. We aim to describe the results of the first round of this study on cervical cancer screening here.

Methods

This study began in September 2013 with recruitment completed in March 2016. Women aged 30–49 years were divided into 2 groups: those who received uterine cervical cytology alone in the first year (control group), or those who received a combination of cytology and HPV testing (intervention group), based on their age. After first screening, women with positive result of cytology or positive HPV test required referral. We summarized the results of the first round of cervical cancer screening.

Results

Of the 25,074 women who were eligible for the study, 13,845 women (55.2%) were screened with cytology alone; 11,229 women (44.8%) received a combination of cytology and HPV testing. After screening, 407 women (2.9%) in the control group and 1,003 women (8.9%) in the intervention group required referral, respectively. Adding HPV testing increased referral rate significantly (p<0.001).

Conclusion

After first screening, introduction of HPV testing appears to contribute to significantly higher referral rates, suggesting that the number of colposcopies as a detailed examination may increase. These preliminary findings suggest that if HPV testing is introduced into screening, medical institutions need to be prepared for an increasing number of follow-up examinations.

Public health impact and cost effectiveness of routine and catch-up vaccination of girls and women with a nine-valent HPV vaccine in Japan: a model-based study

Background

Combined with cancer screening programs, vaccination against human papillomavirus (HPV) can significantly reduce the high health and economic burden of HPV-related disease in Japan. The objective of this study was to assess the health impact and cost effectiveness of routine and catch-up vaccination of girls and women aged 11–26 years with a 4-valent (4vHPV) or 9-valent HPV (9vHPV) vaccine in Japan compared with no vaccination.

Methods

We used a mathematical model adapted to the population and healthcare settings in Japan. We compared no vaccination and routine vaccination of 12–16-year old girls with 1) 4vHPV vaccine, 2) 9vHPV vaccine, and 3) 9vHPV vaccine in addition to a temporary catch-up vaccination of 17–26 years old girls and women with 9vHPV. We estimated the expected number of disease cases and deaths, discounted (at 2% per year) future costs (in 2020 ¥) and discounted quality-adjusted life years (QALY), and incremental cost effectiveness ratios (ICER) of each strategy over a time horizon of 100 years. To test the robustness of the conclusions, we conducted scenario and sensitivity analyses.

Results

Over 100 years, compared with no vaccination, 9vHPV vaccination was projected to reduce the incidence of 9vHPV-related cervical cancer by 86% (from 15.24 new cases per 100,000 women in 2021 to 2.02 in 2121). A greater number of cervical cancer cases (484,248) and cancer-related deaths (50,102) were avoided through the described catch-up vaccination program. Routine HPV vaccination with 4vHPV or 9vHPV vaccine prevented 5,521,000 cases of anogenital warts among women and men. Around 23,520 and 21,400 diagnosed non-cervical cancers are prevented by catch-up vaccination among women and men, respectively. Compared with no vaccination, the ICER of 4vHPV vaccination was ¥975,364/QALY. Compared to 4vHPV, 9vHPV + Catch-up had an ICER of ¥1,534,493/QALY.

Conclusions

A vaccination program with a 9-valent vaccine targeting 12 to 16 year-old girls together with a temporary catchup program will avert significant numbers of cases of HPV-related diseases among both men and women. Furthermore, such a program was the most cost effective among the vaccination strategies we considered, with an ICER well below a threshold of ¥5000,000/QALY.

Cervical Cancer Screening Guidelines in the Postvaccination Era: Review of the Literature

Cervical cancer is relatively rare in high-income countries, where organized screening programs are in place, as well as opportunistic ones. As the human papillomavirus (HPV) vaccination rates increase, the prevalence of cervical precancers and cancers is going to decrease rapidly very soon, even if, in the most optimistic scenario, it is unlikely that optimal vaccination coverage will be achieved. Then, the optimal screening paradigm for cervical cancer prevention in the postvaccination era is still debated. Screening guidelines are being developed with the aim of reducing the number of tests a woman needs during her lifetime, in order to receive the maximum benefit from screening, while decreasing potential harms that may result with the use of a screening strategy (overdiagnosis, overtreatment, anxiety, and costs). With this purpose in mind, new management guidelines for cervical cancer screening abnormalities are recommendations based on risks, not on results. This review aims to summarize the process that led to the introduction of the HPV DNA test in screening programs and the different screening strategies. Moreover, it aims to introduce the new risk-based guidelines for the future, where full HPV genotyping can resize the risk on the basis of specific high-risk genotypes. In the same way, the data regarding HPV vaccination could be introduced as soon as women vaccinated with the nonavalent vaccine reach the screening age, with the recommendation of a prolonged screening interval.

Comparison Study of Self-Sampled and Physician-Sampled Specimens for High-Risk Human Papillomavirus Test and Cytology

OBJECTIVE

The objective of this study was to calculate the positive rate and overall concordance rate of high-risk human papillomavirus (hrHPV) test and cytology using self-sampled and physician-sampled cervicovaginal tests and to compare both specimens.

METHODS

In collaboration with 3 private hospitals in Sapporo city, 300 women visiting these organizations were enrolled in the study by previously signing an informed consent. From these women, both types of samples (self-obtained and physician-sampled) were obtained at the same time. HrHPV test and cytology were performed on both specimens, and the positive rate and overall concordance rate were calculated to compare both specimens.

RESULTS

HrHPV-positive women were 13.7% in physician-sampled specimens and 14.7% in self-sampled specimens, with an overall concordance rate of 96.3% (95% confidence interval [CI]: 94-98%). On the other hand, the positive rate of the cases higher than or equal to atypical squamous cells of undetermined significance (ASCUS) on cytology was different between both groups, that is, 12.3% in physician-obtained and 5.3% in self-sampled specimens; the overall concordance rate was 90.7% (95% CI: 87-94%), indicating an apparent decrease in the positive rate of cytology in self-obtained specimens.

CONCLUSION

HrHPV test and cytology were performed on parallel samples obtained by the patients with a self-sampling tool and by the physician. The positive rate of cytology was considerably different between these specimens, while almost equivalent results were obtained for hrHPV test in both specimens. It was concluded that hrHPV test may be safely and accurately performed on self-obtained cervicovaginal samples by the help of a self-sampling device in the Japanese population as a first screening tool, with equivalent results to physician-obtained specimens.

A comparison of liquid-based and conventional cytology using data for cervical cancer screening from the Japan Cancer Society

OBJECTIVE

Liquid-based cytology has replaced conventional cytology in cervical cancer screening in many countries. However, a detailed comparison of liquid-based cytology with conventional cytology has not been reported in Japan. Therefore, the aim of the study is to evaluate efficacy of liquid-based cytology in Japan.

METHODS

We first evaluated the prevalence of use of liquid-based cytology and then examined the efficacy of liquid-based cytology and conventional cytology for detecting CIN and the rate of unsatisfactory specimens using data from cancer screening collected by the Japanese Cancer Society from FY2011 to FY2014. A Poisson regression model with random effects analyses was used to classify histological outcomes and unsatisfactory specimens using liquid-based cytology compared to conventional cytology.

RESULTS

A total of 3 815 131 women were analyzed in the study. The rate of liquid-based cytology increased from approximately 8% in FY2011 to 37% in FY2014. Compared to conventional cytology, the detection rates with liquid-based cytology were significantly higher (1.42 times) for CIN1+ [detection rate ratio (DRR) = 1.42, 95% confidence interval (CI) 1.35-1.48, P < 0.001] and CIN2+ (DRR = 1.16, 95% CI 1.08-1.25, P < 0.001). Positive predictive value ratios of CIN1+ and CIN2+ were also significantly higher for liquid-based cytology than for conventional cytology. However, there was no significant difference between liquid-based cytology and conventional cytology for detection rates and positive predictive values of CIN3+ and cancer. The rate of unsatisfactory specimens was significantly lower with liquid-based cytology compared to conventional cytology (DRR = 0.07, 95% CI 0.05-0.09, P < 0.001).

CONCLUSIONS

In order to avoid the unsatisfactory specimens in cervical cancer screening, the results of this study did indicate that liquid-based cytology was more useful than conventional cytology in practical standpoints.

Cervical cancer screening rates before and after the Great East Japan Earthquake in the Miyagi Prefecture, Japan

After disasters, issues pertaining to women’s health such as irregular periods and bleeding are well surveyed. However, the management of women’s health, especially changes in the rate of health checkups, has not been investigated. In the present study, we focused on the change in the cervical cancer screening rates (CCS-Rs) before and after the Great East Japan Earthquake in Miyagi Prefecture, Japan. The earthquake had a magnitude of 9.0, a profound disaster. We examined the CCS-R from 2009 to 2016 in 45 areas of the Miyagi Prefecture. Screening was completed using mobile vans. In the 4 areas impacted by the tsunami after the earthquake, a marked decrease in the CCS-R was observed in 2011 when the earthquake took place (more than a 3% decrease compared with that in the previous year). The CCS-Rs in these 4 regions remained lower in 2016 than in the previous year. In 2009–2016 except for 2014, CCS-Rs in coastal areas (9 areas) were significantly lower than those in the non-coastal areas (36 areas). A delay in seeking healthcare, also known as “patient’s delay,” is considered as one of the problems of cancer treatment in affected areas. It is possible that a decrease in the CCS-R may lead to low detection of advanced stages of cancer. Therefore, the establishment of a comprehensive medical system including medical screening after a disaster is important for the management of women’s health.

Detection of HPV RNA molecules in stratified mucin-producing intraepithelial lesion (SMILE) with concurrent cervical intraepithelial lesion: a case report

Background

Stratified mucin-producing intraepithelial lesion (SMILE) is a rare precursor lesion in the uterine cervix that is considered a variant of adenocarcinoma in situ (AIS). Although human papillomavirus (HPV) is thought to be related to the development of SMILE, there is little information available on the detection of HPV integrated into the lesion.

Case presentation

A 30-year-old female underwent a routine uterine cervical cancer screening, and her Pap smear indicated the possible existence of atypical glandular cells. A cervical biopsy with endocervical curettage was performed. The histopathological analysis showed that she had SMILE and high-grade squamous intraepithelial lesion (HSIL) on her cervix. The lesion was found to be positive for HPV genotypes 52 and 68 by multiplex PCR. In situ hybridization with HPV RNA probes revealed that these HPV types were involved in the onset of HSIL and SMILE, respectively.

Conclusions

Rare, high-risk HPV genotypes may contribute to the development of SMILE, and their detection can be useful for preventing the progression to carcinoma and ensuring adequate patient management.

Population-based cohort study assessing the efficacy of cervical cytology (Pap smear) and human papillomavirus (HPV) testing as modalities for cervical cancer screening

In cervical cancer screening, several trials have shown that human papillomavirus (HPV) testing or combined HPV testing and cytology leads to earlier detection of cervical intraepithelial neoplasia Grade 3 or worse (CIN3+) compared with cytology alone. However, the availability of similar evidence in our country remains limited. In 2013, 34 local governments were selected to administer a cervical cancer screening program utilizing either cytology alone or in combination with HPV testing. We planned a cohort study to assess the effectiveness of HPV testing as a modality for cervical cancer screening. The primary outcome of this study was the incidence of CIN3+ in each group, as well as to assess the risks and benefits of receiving screening for women in both groups. These results will contribute to elucidating the details of the positive and negative impacts of introducing HPV testing into a population-based cervical cancer screening program in Japan.

How asymptomatic are early cancer patients of five organs based on registry data in Japan

BACKGROUND

One reason for the low cancer screening rate in Japan is that people are not concerned about cancer if they do not have symptoms.

METHODS

The authors retrospectively analyzed 18,405 cancer patients using hospital-based cancer registry data collected between 2007 and 2013 at the 13 hospitals of Shimane Prefecture, Japan. The symptomatic rates of five cancers (stomach, colorectal, lung, breast, and cervix) at each stage and the time of early diagnosis were investigated. The early detection rates of symptomatic and asymptomatic individuals were investigated.

RESULTS

The percentages of symptomatic cases tended to increase with progressive stages. The odds ratio (OR) of stage IV compared with that of stage I was 12.23 for stomach, 7.21 for colorectal, 16.91 for lung, 10.30 for breast, and 51.62 for cervical cancer. The proportions of early symptomatic cases at the time of diagnosis were low. Compared with the percentage of early symptomatic cases of stomach cancer of 25.5%, the percentage of lung cancer was the lowest, at 8.2% (OR 0.26), and the percentage of breast cancer was the highest, at 30.2% (OR 1.26). The percentages of early symptomatic cases of colorectal and cervical cancer were 18.9% (OR 0.68) and 19.9% (OR 0.73), respectively. The early detection rates of the asymptomatic and symptomatic groups were 77.6 and 36.1%, respectively.

CONCLUSION

Cancer registry data indicate that early cancers are asymptomatic, and once symptoms appear, treatment may not be effective. Policy makers should inform people of the necessity of cancer screening before they have symptoms.

Frequency of unsatisfactory cervical cytology smears in cancer screening of Japanese women: A systematic review and meta-analysis

The Bethesda system (TBS) has been used for cervical cytological diagnosis in Japan since 2008. Evaluation of specimen adequacy is the most important aspect of quality assurance and for precise diagnosis in TBS. A systematic review and meta‐analysis were carried out to assess the unsatisfactory specimen rate in the primary cervical cancer screening setting in Japan. Ovid Medline and Ichushi‐Web databases were searched from inception through to May 2017. Prospective and retrospective studies that reported the proportion of unsatisfactory specimens in healthy asymptomatic Japanese women in a cervical cancer screening program were eligible for inclusion; 17 studies were included in the meta‐analysis. The random‐effects model meta‐analysis calculated summary estimates of the unsatisfactory rate of 0.60% (95% confidence interval [CI], 0.18‐1.96%; I² = 99%) for conventional cytology and 0.04% (95% CI, 0.00‐0.35%; I² = 99%) for liquid‐based cytology (LBC). However, comparative results between conventional and liquid‐based cytology, based on four direct and nine comparative studies, showed no significant difference (summary odds ratio = 3.5 × 10⁻² favoring LBC [95% CI, 6.9 × 10⁻⁴‐1.7]; I² = 98%). In the subgroup analyses and meta‐regressions, use of non‐cotton devices for conventional cytology and use of a particular platform for LBC were associated with lower unsatisfactory rates. Meta‐regression also suggested chronological improvement in unsatisfactory rates for both tests. In Japanese cervical cancer screening programs, conventional cytology remains prevalent. Future research needs to focus on evaluating the impact of screening programs using LBC by comparing the accuracy, performance, and cost‐effectiveness with conventional cytology in the Japanese population.

Identifying a candidate population for ovarian conservation in young women with clinical stage IB-IIB cervical cancer

This study seeks to identify risk factors associated with ovarian metastasis and to characterize a population with minimum risk of ovarian metastasis in young women with stage IB-IIB cervical cancer. This was a nation-wide multicenter retrospective study in Japan examining consecutive cases of surgically-treated women with clinical stage IB-IIB cervical cancer who had oophorectomy at radical hysterectomy (n = 5,697). Multivariable analysis was performed to identify independent risk factors for ovarian metastasis. Ovarian metastasis was seen in 70 (1.2%, 95% confidence interval 0.9-1.5) cases. In the entire cohort, adenocarcinoma, lympho-vascular space invasion, uterine corpus tumor invasion, and pelvic/para-aortic nodal metastases remained independent risk factors for ovarian metastasis (all, adjusted-p < 0.05). In a sensitivity analysis of 3,165 women aged <50 years (ovarian metastasis, 1.0%), adenocarcinoma, parametrial tumor involvement, uterine corpus tumor involvement, and pelvic/para-aortic nodal metastases remained independent risk factors for ovarian metastasis (all, adjusted-P < 0.05). In the absence of these five risk factors (representing 46.1% of women aged <50 years), the incidence of ovarian metastasis was 0.14%. With the presence of adenocarcinoma alone (representing 18.9% of women aged <50 years), the incidence of ovarian metastasis was 0.17% and was not associated with increased risk of ovarian metastasis compared to the subgroup without any risk factors (p = 0.87). In conclusion, nearly two thirds of women aged <50 years with clinical stage IB-IIB cervical cancer had no risk factor for ovarian metastasis or had adenocarcinoma alone: these subgroups had ovarian metastasis rates of around 0.1% and may be a candidate population for ovarian conservation at surgical treatment.

Resource Use and Cost of Treating Human Papillomavirus-Related Lesions in Japanese Women

BACKGROUND

Human papillomavirus (HPV) infection is established as a necessary causal factor in several pathologies including cervical cancer (CC), which recorded over 11,000 new cases in 2011 in Japan. Nevertheless, cost burden data of human papillomavirus-related diseases in Japan are lacking.

OBJECTIVES

To evaluate resource use and costs in women with HPV-related lesions.

METHODS

A retrospective study using insurance claims databases was performed to assess the annual medical cost for suspected cervical intra-epithelial neoplasia (CIN)/CC, genital warts (GWs), CIN (all grades), and CC. Information on the treatment of GWs was obtained from the Claims Database developed by Japan Medical Data Center Co., Ltd. Information on CIN and CC was obtained from the Evidence-Based Medicine provider database developed by Medical Data Vision Co., Ltd. Databases cover about 1% of the Japanese population. Total annual cost in Japanese yen (¥) per patient in 2011 was calculated on the basis of resource used and unit costs from Japan medical insurance tariffs.

RESULTS

Average annual costs were as follows: GWs, ¥34,424; suspected CIN/CC, ¥6,240; CIN 1, ¥17,484; CIN 2, ¥46,583; CIN 3, ¥166,227; and CC, ¥474,756.

CONCLUSIONS

To our knowledge, this is the first observational study to estimate the annual medical costs of HPV-related diseases in Japan using real-world data collected in routine clinical practice. It could provide help in estimating the economic burden of HPV-related lesions in Japanese women.

Does lack of resources impair access to breast and cervical cancer screening in Japan?

Objectives

To assess the impact of the quantity of resources for breast and cervical cancer screening on the participation rates in screening in clinical settings in municipalities, as well as to clarify whether lack of resources impairs access to cancer screening in Japan.

Methods

Of the 1,746 municipalities in 2010, 1,443 (82.6%) and 1,469 (84.1%) were included in the analyses for breast and cervical cancer screening, respectively. In order to estimate the effects of the number of mammography units and of gynecologists on the participation rates in breast and cervical cancer screening in clinical settings, multiple regression analyses were performed using the interaction term for urban municipalities.

Results

The average participation rate in screening in clinical settings was 6.01% for breast cancer, and was 8.93% for cervical cancer. The marginal effect of the number of mammography units per 1,000 women was significantly positive in urban municipalities (8.20 percent point). The marginal effect of the number of gynecologists per 1,000 women was significantly positive in all municipalities (2.54 percent point) and rural municipalities (3.68 percent point).

Conclusions

Lack of mammography units in urban areas and of gynecologists particularly in rural areas impaired access to breast and cervical cancer screening. Strategies are required that quickly improve access for the residents and increase their participation rates in cancer screening.

Primary care patient experience and cancer screening uptake among women: an exploratory cross-sectional study in a Japanese population

BACKGROUND

Patient experience and clinical quality, which are represented by preventive care measures such as cancer screening, are both widely used for the evaluation of primary care quality. The aim of this study was to examine the association between patient experience and cancer screening uptake among women in a Japanese population.

METHODS

We conducted a cross-sectional mail survey. The questionnaire was sent to 1000 adult female residents randomly selected from a basic resident register in Yugawara town, Kanagawa, Japan. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT) and uptake of breast and cervical cancer screening.

RESULTS

The overall response rate was 46.5%. Data were analyzed for 190 female participants aged 21-74 years who had a usual source of primary care. Multivariate logistic regression analyses revealed that the JPCAT total score was significantly associated with uptake of breast cancer screening [odds ratio (OR) per 1 standard deviation increase = 1.63; 95% CI 1.11-2.41], but not with uptake of cervical cancer screening (OR per 1 standard deviation increase = 1.47; 95% CI 0.97-2.24).

CONCLUSIONS

Patient experience of primary care was associated with uptake of breast cancer screening among Japanese women. The results of our study might support the argument that patient experience of primary care and the clinical process of preventive care, such as breast cancer screening, are linked.

Psychological impact of positive cervical cancer screening results among Japanese women

BACKGROUND

While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening.

METHODS

We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress.

RESULTS

Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32-3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69-3.01) and marital status (OR 1.32; 95 % CI 1.02-1.70).

CONCLUSIONS

Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

Challenges in breast and cervical cancer control in Japan

Since the mid-1990s, there has been an increasing incidence of, and mortality from, cervical and breast cancers in Japan. Such an increase has raised concerns over the efficiency of Japan's screening programmes for these cancers. Although citizens benefit from universal health coverage, the Japanese health insurance system mostly focuses on tertiary prevention and disease treatment, while secondary prevention (screening) is low priority. Citizens have multiple opportunities to be screened for cancer-either through programmes organised by municipalities, or individual or collective, opportunistic and comprehensive health check-ups on a voluntary basis. Despite this, however, participation is as low as 35% of the target population for both cancers. In this Policy Review, we discuss the challenges in the prevention of breast and cervical cancers in Japan, particularly focusing on the structure of the National Health Insurance system and the National Cancer Control Plan, reasons for low participation as a result of social and political attitudes, as well as providing recommendations to overcome these challenges. Japanese women would benefit from new measures to increase participation, a national data surveillance programme to monitor screening activities, and the implementation of a quality assurance system among all providers.

Cervical Cancer Screening: Recommendations for Muslim Societies

BACKGROUND

The overall cervical cancer incidence rate is low in Iran; however, because of a higher risk of death for cervical cancer, a disease that kills women in middle age, a cervical cancer control program is needed. The aim of this study was to provide consensus recommendation for cervical cancer prevention in Iran and other Muslim societies with low incidences of cervical cancer.

MATERIALS AND METHODS

Through a practical guideline development cycle, we developed six questions that were relevant to produce the recommendation. We reviewed 190 full text records of cervical cancer in Iran (1971 to 2013) of which 13 articles were related to the data needed to answer the recommendation questions. We also reviewed World Health Organization, IARC, GLOBOCAN report, Iran Ministry of Health cancer registry report and 8 available foreign countries guidelines. Lastly, we also evaluated the Pap smear results of 825 women who participated in the Iranian HPV survey, of whom 328 were followed-up after a 5-year interval.

RESULTS

The obtained data highlighted the burden of HPV and cervical cancer situation in Iran. Experts emphasized the necessity of a cervical cancer screening program for Iranian women, and recommended an organized screening program with a cytological evaluation (Pap smear) that would start at the age of 30 years, repeated every 5 years, and end at the age of 69 years. Meanwhile, there is no need for screening among women with a hysterectomy, and screening should be postponed to post-partum among pregnant women.

CONCLUSIONS

An organized cervical cancer screening is a necessity for Iran as more than 500-900 women in middle age diagnosed with an invasive cervical cancer every year cannot be ignored. This recommendation should be taken into account by the National Health System of Iran and Muslim countries with shared culture and behavior patterns. CUBA HPV test could be consideration in countries Muslim country with appropriate budget, resources and facility.

Comparison of Pap Smear and Colposcopy in Screening for Cervical Cancer in Patients with Secondary Immunodeficiency

Introduction

Cervical cancer is the second most common cancer among women worldwide. The sensitivity of conventional Pap smear in detecting cervical lesions before cervical cancer is 51%, which means the false negative value is 49%. The aim of this study was to compare two methods for screening for cervical cancer in patients with secondary immunodeficiency, i.e., the conventional Pap smear and colposcopy.

Methods

This cross-sectional study was conducted on 101 immunodeficient patients who were referred to the Gynecologic Clinic at Shahid Sadughi Hospital in Yazd from March 2011 to August 2012. All patients underwent the Pap test, a colposcopy, and a cervical biopsy, with the latter being considered as the gold-standard test.

Results

The most frequency of immunodeficiency was noted among patients with rheumatoid arthritis (53.3%), and this was followed by patients who were undergoing chemotherapy (30.7%), patients with lupus erythematosus (12.9%), and patients with AIDS (3%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the Pap smear were 18.2, 98.5, 85.5, 71.3, and 72.2%, respectively. The respective values for colposcopy were 66.7, 98.94, 80, 97.9, and 97%, respectively.

Conclusion

In this study the accuracy, sensitivity, specificity, and negative predictive values of colposcopy were higher than those for the Pap smear in detecting high-grade, cervical, pre-malignant lesions (cervical intraepithelial neoplasia: CIN ≥ 2). Therefore, an annual colposcopy is advised for secondary immunodeficient patients instead of a Pap smear.

Obstetrical prognosis of patients with cervical intraepithelial neoplasia (CIN) after "coin-shaped" conization

PURPOSE

Uterine cervical conization is related to adverse pregnancy outcomes in subsequent pregnancies. To deal with this problem, we started conservative coin-shaped conization for reproductive-aged patients with cervical intraepithelial neoplasia (CIN). Here we report both the obstetrical and oncological impacts of this operation in comparison with the standard cone-shaped resection.

METHODS

A total of 401 women 44 years old or younger were treated in our hospital by CO2 laser conization between 2003 and 2012, and subsequently 50 patients became pregnant. The patients were divided into two groups, a standard cone-shaped conization group (until 2008) and a shallow coin-shaped conization group (beginning in 2008). The pregnancy courses and oncological prognoses of these two groups were studied.

RESULTS

Cone height reduction of about 3 mm was done. However, there were no significant differences between the two groups with regard to the occurrence of oncological complications. In the standard conization group, 18 of the 25 patients delivered at term. In the coin-shaped conization group, 20 of the 25 patients delivered at term. There were no significant differences between the two groups with regard to the occurrence of various obstetrical complications. However, the reduction rate of cervical length over the pregnancy was smaller in the coin-shaped group and the number of patients with a short cervix length of 2 cm or less was smaller in the coin-shaped group.

CONCLUSIONS

Although conservative coin-shaped conization did not markedly improve the obstetrical prognosis, this operative procedure improved the reduction rate of uterine cervical length over the pregnancy without any increase in oncological complications.

The Korean guideline for cervical cancer screening

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).

The Korean guideline for cervical cancer screening

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).

Recent progress and future direction of cancer epidemiological research in Japan

In 2006, the Cancer Control Act was approved and a Basic Plan, to Promote the Cancer Control Program at the national level, was developed in 2007. Cancer research is recognized as a fundamental component to provide evidence in cancer control program. Cancer epidemiology plays central role in connecting research and policy, since it directly deals with data from humans. Research for cancer epidemiology in Japan made substantial progress, in the field of descriptive studies, cohort studies, intervention studies and activities for summarizing evidences. In future, promoting high-quality large-scale intervention studies, individual-level linkage studies, simulation models and studies for elderly population will be of great importance, but at the same time research should be promoted in well-balanced fashion not placing too much emphasis on one particular research field.

Aberrant DNA methylation of DLX4 and SIM1 is a predictive marker for disease progression of uterine cervical low-grade squamous intraepithelial lesion

BACKGROUND

A few uterine cervical low-grade squamous intraepithelial lesions (LSILs) are known to progress with high-risk human papillomavirus (hrHPV).

METHODS

One hundred and thirteen patients were classified into four groups according to their cervical cytology, hrHPV infection, and follow up. Cytology samples were examined for aberrant DNA methylation of DLX4 and SIM1 genes and protein expressions. CaSki cells were treated with 5-Aza-2'-deoxycytidine (5-aza-dC).

RESULTS

Group 1 was negative for intraepithelial lesions or malignancies. LSIL in group 2 showed a continuance of LSIL for longer than 365 days and LSIL in group 3 showed an upgrading to high-grade (H) SIL or higher (HSIL+) within 365 days of LSIL diagnosis. Group 4 was squamous cell carcinoma. All but group 1 were infected with hrHPV. Significant differences existed in the frequency of DNA methylation between groups 2 and 3 (p = 0.044), between groups 3 and 4 (p = 0.020) for DLX4, and between groups 1 and 3 (p = 0.0003), and groups 2 and 3 (p = 0.005) for the SIM1 gene. DLX4 protein expression was significantly reduced in the DLX4 methylation positive tissues (p = 0.008). The 5-aza-dC treatment restored DLX4 mRNA expressions of CaSki cells (p < 0.005). The LSIL cases with DNA methylation of the SIM1 gene, or both genes, progressed faster to HSIL+ than did the others (p = 0.033 and p = 0.045, respectively).

CONCLUSION

Aberrant DNA methylation of the DLX4 and SIM1 genes should be a novel progression marker for uterine cervical LSIL with hrHPV infection.

What is the most effective strategy for improving the cancer screening rate in Japan?

BACKGROUND

Cancer screening rates in Japan are much lower than those in Western countries. This study evaluated the relationship between cancer screening rates and strategies used to improve screening rates, and determined which strategy is the most effective.

MATERIALS AND METHODS

All municipalities are responsible for conducting gastric, lung, colorectal, cervical, and breast cancer screenings in Japan. Of the 1,746 municipalities in total, 92-99% were included in the analyses for each cancer screening. Using national data in 2009, the correlations between cancer screening rates and strategies for improving screening rates of all municipalities, both large (populations of over 30,000) and small (populations of under 30,000), were determined. The strategies used were as follows: sending personal invitation letters, personal visits by community health workers, use of a clinical setting for screening, and free screening.

RESULTS

Of all four strategies used to improve cancer screening rates, sending personal invitation letters had the highest correlations with all screening rates, with the exception of breast cancer screening. The partial correlation coefficients linking this strategy with the screening rates in all municipalities were 0.28, 0.32, 0.30, and 0.26 for gastric, lung, colorectal, and cervical cancer screening, respectively. In large municipalities, the correlations between the number of examinees in a clinical setting and the screening rates were also relatively high, particularly for cervical cancer screening (r=0.41).

CONCLUSIONS

Sending personal invitation letters appears to be particularly effective in improving cancer screening rates in all municipalities. All municipalities should implement a system that sends personal invitation letters for cancer screening. In large municipalities, increasing the availability of screening in a clinical setting is also effective in improving cancer screening rates.

A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan

AIM

Japan has low rates of cervical cancer screening and Human papilloma virus (HPV) vaccination. This research examines the effectiveness of a family medicine resident-led, intervention in increasing knowledge about HPV and cervical cancer in middle school-girls and increasing knowledge and intention to have cervical cancer screening in their mothers.

METHODS

We utilized a pre-test/post-test intervention design in three rural middle schools with 7(th) grade middle school-girls and their mothers. A school-based activity educated girls about HPV and cervical cancer. A home-based activity utilized a homework assignment for girls and their mothers. Pre/post intervention surveys were completed by the girls and their mothers. Major outcomes included changes in knowledge among girls and mothers and barriers to be screened for cervical cancer among mothers.

RESULTS

Sixty-five students and sixty-three mothers completed the study. Two out five mothers were not in compliance with current screening recommendations. Identified barriers included: embarrassment (79%), poor access (56%), fear of having cancer (52%), and cervical cancer screening being an unknown procedure (46%). Forty-four percent of mothers deemed their daughters to be at risk for cervical cancer. Trusted sources of information included: doctors (97%), newspapers/television (89%), government (79%), the Internet (78%), and friends (62%). Student knowledge scores (7-point scale) improved significantly from pre- to post-intervention (4.8 vs. 5.9, p < 0.001). Knowledge scores (14-point scale) among mothers also significantly improved (11.7 vs. 12.0, p = 0.024).

CONCLUSIONS

These data suggest a community-based intervention on a sensitive topic by family medicine residents can be implemented in middle schools, can improve school-girls' knowledge about HPV and cervical cancer, and can reach their mothers. Additional research could examine whether those intending to be screened receive screening and how to reach women who still resist screening.

Attitudes toward cervical cancer screening among women receiving human papillomavirus vaccination in a university-hospital-based community: interim 2-year follow-up results

AIM

This study investigated the status of cervical cancer screening among women in a university hospital-based community who received catch-up human papillomavirus (HPV) vaccinations as a basic element of our community-based cervical cancer prevention advocacy.

METHODS

Self-administered questionnaires were distributed to 173 women working or studying in the community at their first HPV vaccination in 2010, at the third vaccination, and 2 years later. Their demographics and attitudes toward the Pap test were analyzed.

RESULTS

The median age of the participants was 27.5 years and 88.2% were sexually active. Before the first vaccination, 38.5% (57/148) of the screening targets had never had a Pap test. Among the women who completed the third vaccination, Pap test experiences within the recent 2 years increased from 45.3% (63/139) at the first vaccination to 71.2% (99/137) at the third vaccination, and 67.5% (54/80) 2 years later. In 45.3% of the screening targets who had never had a Pap test at the time of their first HPV vaccination, their first Pap test was followed by their vaccination.

CONCLUSIONS

Having biennial Pap tests in accordance with the Japanese national cancer screening guideline was shown to be difficult even for the women in the medical community; however, education about the Pap test and the efficacy of HPV vaccination in providing opportunistic screening encouraged them to have their first or suspended Pap test. Our interim data suggest the need for urgently changing the cervical cancer prevention strategy for young adult women who are excluded from the national HPV vaccine program.

The four steps in the prevention of human papillomavirus-associated neoplasia: considerations for preventive measures, screening, disease impact, and potential overtreatments in HPV-related pathology

There is no cure currently available for HPV infections, although ablative and excisional treatments of some dysplasias often result in a clinical and virological cure. Effective control measures of HPV-associated cancers rely on the prevention at four different levels. Apart from sexual abstinence, primary prevention is realized through vaccines targeting the most frequent HPV types: negative attitudes towards HPV vaccination and high costs are the main obstacles. The aim of secondary prevention is to detect precancerous changes before they develop into invasive cancer, while tertiary prevention involves actual treatment of high-grade lesions: in many countries routine screening with cytology is being challenged with HPV DNA testing. Quaternary prevention comprehends those actions adopted to mitigate or avoid unnecessary or excessive medical interventions, and may well be addressed in avoiding treatments for low-grade intraepithelial neoplasia. Though some gynecologists commonly recommend treatment for low-grade disease and women tend to prefer active management if not properly informed, harms arising from unnecessary treatments, increased costs, work overload for second-level health services, and induced psychosocial distress are causing on-going problems. Prevention efforts of genital HPV-associated cancers should concentrate in: (1) enhancing primary prevention through vaccination of all eligible subjects, (2) achieving high levels of adherence to routine screening programs, (3) treating precancerous lesions, and (4) monitoring current guidelines recommendations to avoid overtreatments. Novel research projects should be designed to study the delicate mechanisms of immune response to HPV.

Association between cancer screening behavior and family history among Japanese women

OBJECTIVE

To examine lifestyle habits and cancer screening behavior in relation to a family history of cancer among Japanese women.

METHODS

A cross-sectional study was conducted based on baseline data from the Japan Nurses' Health Study collected from June 2001 to March 2007. Participants were 47,347 female nurses aged 30-59 years residing in 47 prefectures in Japan. We compared lifestyle habits and the utilization of cancer screenings (cervical and breast) between women with and without a family history of the relevant cancer.

RESULTS

Although there were no differences in lifestyle habits with the exception of smoking status, women with a family history of uterine cancer were more likely to have undergone cervical cancer screenings (p<0.01). Women with a family history of breast cancer were also more likely to have undergone breast cancer screenings regardless of their age (p<0.01), but lifestyle behaviors did not differ. Among women with a family history of uterine cancer, those with a sister history were more likely to have undergone not only cervical (OR, 1.89; 95% CIs, 1.39-2.58), but also breast cancer screenings (OR, 1.54; 95% CIs 1.13-2.09).

CONCLUSION

Having a family history of cancer was associated with cancer screening behavior, but not health promotive behaviors.