Pattern of Cervical Screening Utilization in Italy

Attendance to a Screening Program for Cervical Cancer in the City of Florence

The study was aimed to assess: a) the proportion of true refusers among non-attenders resulting from residents and screening database matching, b) the typology of refusers compared to attenders, and c) the reasons for non-attendance as stated by refusers. Three hundred and forty-one non-attenders according to computer-produced lists were interviewed: 29 were not evaluable, 148 had had a Pap test, 18 had not attended for valid reasons, and 146 were true refusers; 94 refusers accepted the interview as far a points b) and c) were concerned. Ninety-four attenders, matched by age and residence, were interviewed for comparison. Attendance at private laboratories or incorrect identification of subjects on the screening record accounted for 45 % or 55 % of misclassified cases, respectively. The adjusted true refusal rate in the last 10 years was 18.1 % compared to a computer-assessed non-attendance rate of 40.7 %. Refusal was significantly associated to socioeconomic status (geographic origin, working activity and educational level of both women and husbands), whereas no significant association was observed for sexual history (deliveries, age at first sexual relation, number of partners) or health-related behavior. Attendance and counseling at the gynecologist's office were strongly associated to attendance, and gynecologists should be stimulated to promote opportunistic screening. The belief that screening is useless in the absence of symptoms, the fear of cancer being detected, postponement or laziness were the reasons for non-attendance stated by 80% of refusers. Improving knowledge about the purpose of the Pap test should be the main goal of any action aimed to improve screening attendance.

The Effect of Cytological Screening on Cervical Neoplasia in the Italian Province of Varese

In the Varese province (409,142 female inhabitants in 1981), which has been covered by a cancer registry since 1976, cytologic screening for cervical cancer began in the early sixties in the municipality of Busto Arsizio (41,818 female inhabitants in 1981) and subsequently spread to the rest of the province. The distribution by age of cytologic smears and of detected in situ cancer reveals a more frequent attitude to be screened for women aged between 25 and 54 years. Overall, the incidence rate (world standardized) for invasive cancer in the province decreased from 10.3/100,000 women-year in the period 1976-81 to 7.5/100,000 in 1982-87. In Busto Arsizio a survey of the hospital archives has been carried out to identify the cases of cervical cancer diagnosed from 1966 to 1985: in this 20-year period, the incidence of cervical cancer decreased markedly, but only in those ages frequently screened. In the rest of the province, for the first period of cancer registration (1976-81), the incidence was significantly higher than in Busto Arsizio, especially for ages 35-64. Subsequently, between 1982-87, the cervical cancer incidence was low in both areas. For the period 1976-87, no difference for carcinoma in situ registration rates was observed between the two populations studied. Actually by 1976, when the Lombardy Cander Registry began its activity, the screening was diffuse throughout the province. These observations are consistent with the preventive effect of screening activity.

Characteristics of Women Reporting Cervical Screening

The characteristics of women reporting cervical cytology screening has been evaluated using data from control subjects collected in the framework of a case-control study on invasive cervical cancer conducted since 1981 in the greater Milan area. A total of 515 women admitted for nonneoplastic, non-gynecologic, nonendocrine-related acute conditions to a network of general and university hospitals were interviewed. The frequency of cervical screening utilization decreased with age: regular screening (≥ 3 lifetime Pap smears) was reported by 46% of women aged 44 years or less, but only 11% of those aged 65 or more. Married women reported about 50% more frequently occasional (1 or 2) and about three times regular (≥ 3) cervical screening than unmarried ones. Parous women were more frequently screened, but no trend emerged with number of births. Similarly number of medical consultations in the year before the interview was associated with an increased number of Pap smears. There was no consistent association between number or recency of Pap smears and smoking, sexual habits or education, but women in low social classes tended to be less frequently screened. Ever contraceptive users (oral contraceptives or barrier methods) reported an increased probability to be screened regularly and within two years before the interview.

Cancer Mortality by Urbanization and Proximity to the Sea Coast in Campania Region, Southern Italy

Aims and background

The risk for several cancers is higher in urban than in rural areas. The gradient has seldom been studied in southern Europe.

Patients and methods

The geographical pattern of mortality for different cancers and all causes was studied in the Campania Region (about 5.6 million inhabitants), whose largest town is Naples. The key variables were residence in urban/rural and coastal/inland municipalities. Relative risks of death and corresponding 95% confidence intervals by residence were evaluated by means of Poisson log-linear regression models.

Results

Significantly increased mortality rates in urban compared to rural municipalities were found for several cancer causes of death. In particular, in both sexes, excesses in the order of 30-50% were observed for tobacco-related neoplasms (i.e., larynx, lung, and bladder) and cancers of the intestine, liver, brain, multiple myeloma and non-Hodgkin's lymphoma, in addition to all-cancer, and all-cause mortality. In females, specific excesses were also noticed for cancer of the gallbladder, pancreas, breast and uterus (corpus and cervix). Conversely, significantly decreased mortality rates in urban with respect to rural municipalities were observed for cancer of the oral cavity and pharynx in males. Coastal location and degree of urbanization were strongly correlated, thus showing similar associations with most causes of death. However, a significant excess of cancer of the pleura in males was restricted to coastal municipalities.

Conclusions

Anti-smoking campaigns, sanitation improvements, hepatitis B vaccination, and a decrease in obesity emerge as high priorities with respect to cancer control strategies in the Campania Region, particularly in overpopu-lated, underprivileged urban areas.

A large cross-sectional survey investigating the knowledge of cervical cancer risk aetiology and the predictors of the adherence to cervical cancer screening related to mass media campaign

Objectives. The aims of this study were to compare the characteristics of women who got a Pap-test during the mass media campaign, carried out in an Italian region by broadcasts advertising, and two years later and to identify the determinants of knowledge of cervical cancer etiology and of the adherence to the mass media campaign. Methods. A cross-sectional survey was carried out through a self-administered questionnaire. Results. A total of 8570 randomly selected women were surveyed, 823 of these had a Pap-test during the mass media campaign period and 7747 two years later. Higher educational level, being not married, and living in urban areas were the main independent characteristics associated with a higher level of knowledge of cervical cancer etiology, although a previous treatment following a Pap smear abnormality was the strongest predictor (OR = 2.88; 95% CI: 2.43–3.41). During the campaign period women had the Pap-test more frequently as a consequence of the mass media campaign (OR = 8.28; 95% CI; 5.51–12.45). Conclusions. Mass media campaign is a useful tool to foster cervical screening compliance; however, its short-term effect suggests repeating it regularly.

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95

STUDY OBJECTIVE

Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95.

DESIGN

Rome has a population of approximately 2,800,000, with 6100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence.

MAIN RESULTS

Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women.

CONCLUSIONS

The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce differences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.

Interaction of spontaneous and organised screening for cervical cancer in Turin, Italy

In a screening programme for cervical cancer, coverage of the target population is a major determinant of effectiveness and cost-effectiveness and is one of the parameters for programme monitoring recommended by the "European Guidelines for Quality Assurance". An organised screening programme was started in Turin, Italy, in 1992. Spontaneous screening was already largely present, but coverage (proportion of women who had at least a test within 3 years) was low (< 50%) and distribution of smears uneven. No comprehensive registration of spontaneous smears was available. All women were invited for the first round, independently of their previous test history. Coverage was estimated by integrating routine data from the organised programme with data on spontaneous screening obtained by interviews of a random sample of 268 non-compliers to invitation and 167 compliers. Overall (spontaneous + organised) coverage was estimated to be 74% (95% CI, 71-78%). The proportion of the target population covered as an effect of invitation was estimated to be 17% (95% CI, 15-20%). Invitations were successful in increasing coverage in previously poorly screened groups. Although 20-25% of compliers was estimated to have had further tests before the end of the round, we estimated that switching to a 3-year interval saved approximately 0.26 tests per complier. This suggests that invitations to an organised programme even to previously covered women, can be a cost-effective policy. Our method of estimating overall coverage can be useful in many other European areas where a comprehensive registration of smears is not available.

Characteristics of subgroups of attenders and non-attenders in an organised screening programme for cervical cancer

OBJECTIVE

Several studies have compared attenders and non-attenders in organised cervical screening programmes but few have analysed subgroups of attenders and non-attenders. This study presents social and other characteristics of such subgroups.

SETTING

Aarhus County, Denmark.

METHODS

A case-control study in a cohort of 133,500 women, aged 23-60, included in the programme from 1 October 1990 to 1 April 1994. The participation rate was 75%, and those taking part comprised women with opportunistic screening or who had had a smear owing to symptoms in the previous three years ("active" attenders), and women who were invited for screening because they had not been otherwise tested ("passive" attenders). "Passive" (n = 708) and "active" attenders (n = 692) were compared. Women who had never had a smear test ("never" attenders, n = 287) were then compared with "ever" attenders (n = 1215)-that is, women who had not had a smear test during the previous 42 months, but had had at least one previous test. Data were collected by mailed questionnaires.

RESULTS

The response rate was 81% and 53% for attenders and non-attenders, respectively. After correction for age, there was no difference between the "active" and "passive" attenders for cancer risk factors (smoking, age of first intercourse, number of sexual partners, and social group), or in the degree of responsibility for close relatives, but "active" attenders seemed to have more frequent contact with their general practitioner. "Never" attenders had less frequent contact with their general practitioner than "ever" attenders. They were more often living alone and nullipara, but had no overrepresentation of cancer risk factors.

CONCLUSIONS

Increased effect cannot be obtained by focusing on the described groups, but by increasing the participation rate. "Never" attenders do not belong to a special risk group.

Sociodemographic factors of Pap smear screening in Taiwan

Substantial evidence exists that regular screening is effective in preventing cervical cancer. However, the existing services are underused by many women in Taiwan. To examine the effects of sociodemographic characteristics on the underuse of Papanicolaou (Pap) smear screening, from September to December 1993 we conducted a questionnaire interview on a sample of 4,400 women aged 20 years and older in Taipei city using multistage sampling with probability proportional to size. Our results indicate that 40% of the women sampled have never had a Pap smear and 86% have not had one in the past year. Age is the strongest factor affecting Pap smear use, particularly for women below age 30 and over the age of 65. In addition, women with lower levels of education, women who are not employed, never-married women and women who live outside the city tend to underuse Pap smear screening. These findings help indicate priority groups which should be targeted to increase screening and consequently reduce cervical cancer. Our data also provides a good baseline for comparison of rates of Pap smear screening by various sociodemographic factors in the future.

Trends in cervical cancer incidence in the district of Florence

The trend in cervical cancer incidence in the District of Florence from 1975 to 1989 was investigated. Tuscany Cancer Registry data were available since 1985. Incidence data from 1975 to 1985 were obtained through a retrospective survey of all the Departments of Pathology and Gynaecology in the district. Cytological screening for cervical cancer has been available in the district since 1973, and since 1980 active invitation of residents aged 25 to 59 years has been in use. A significant trend in decreasing incidence was evident for the overall population (P = 0.003) and for 40-49 (P = 0.028), 50-59 (P < 0.001) and 60-69 (P = 0.002) year age groups, whereas no significant trend was observed for the age group 30-39 years. An association between attendance to screening and reduced incidence was evident, in that a greater reduction was evident for those cohorts (ages 50-59 and 60-69) who had a higher compliance to screening 10-15 years before. If the decrease in cervical cancer incidence was spontaneous, a parallel decrease of CIN3, which is commonly assumed to be the precursor of invasive carcinoma, would be expected. On the contrary, the detection rate of CIN3 at first Pap test showed a significant increase in the study period. All these findings suggest that the observed reduction in cervical cancer incidence was mostly due to the effect of screening, and stress the need for optimising the coverage of the invited population.

Factors associated with non-participation of women in a breast cancer screening programme in a town in northern Italy

STUDY OBJECTIVE

The aim was to investigate the reasons for the high percentage of women refusing to attend a breast cancer screening programme in the Health District of Brescia, Italy.

DESIGN

This was a survey of a sample of non-attenders to the programme, who were interviewed using a structured questionnaire.

SETTING

Non-attenders all lived in a central area of the town near the screening centre.

PARTICIPANTS

Of the 612 non-attenders eligible for interview, 183 could not be interviewed: one had died, 86 were away from home at two different visits, 32 were no longer resident at the known address, eight had serious health problems, 17 had undergone mastectomy, and 39 refused the interview. Overall, a total of 429 of the 612 eligible women were interviewed (70.1%).

MEASUREMENTS AND MAIN RESULTS

Attenders and non-attenders were compared with respect to demographic and socioeconomic factors, use of preventive medicine, and prevalence of risk factors for breast cancer. The response was higher among less educated women, married and widowed women, and those born in the province than among more educated, single or divorced, and immigrant women. Most of the women interviewed gave practical reasons for non-participation, but lack of interest/distrust and fear/worry/anxiety also seemed important. The number of non-attenders who had had a Papanicolaou test within the previous three years was three times higher than those who had had mammography, suggesting that non-attenders were more interested in types of preventive medicine other than screening for breast cancer by mammography. Attenders and non-attenders appeared similar as regards distribution of conventional breast cancer risk factors.

CONCLUSIONS

Greater effort in the information campaign might increase the participation rate in screening for breast cancer, although to a lesser extent than expected: if non-attenders potentially recruitable in our screening were added to attenders, overall compliance of the programme was about 75%, lower than that observed in some programmes in northern Europe.

Screening practices and invasive cervical cancer risk in different age strata

Relative and population attributable risks for invasive cervical cancer in different age strata relative to screening practices have been estimated using data from a case-control study conducted since 1981 in the greater Milan area, northern Italy. A total of 548 women under 75 years of age with a histologically confirmed diagnosis of invasive cervical cancer were compared with 515 controls admitted to hospital for a spectrum of nongynecological, hormonal or neoplastic, acute conditions. The percentage of never-screened women increased with age: no Pap smear was reported in 34% of controls aged 44 years or younger and 63% of older women (greater than or equal to 65 years). A similar trend emerged in recency of Pap smear, with 14% of older controls and 52% of the younger group reporting a cervical smear within 3 years before the interview. The number of Pap smears was strongly and inversely related to cervical cancer risk at all ages. Compared with no Pap smear, three or more cervical smears decreased the risk of invasive cervical cancer by about 90%. Compared with women screened the last time 6 years before the interview or never, relative risks were about 60% lower in women reporting their last Pap within 2 years in all age groups. A slightly larger proportion of older cases were attributable to the absence or delay in the screening: population attributable risk estimates were 78% in women up to 55 years of age, and 86% in those 65 years or older. Thus, deficiencies in screening were greater at ages at which the incidence of disease was higher.