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

Determinants of Non-Attendance to Mammographic Screening. Analysis of a Population Sample of the Screening Program in the District of Florence

The characteristics associated with non-attendance to mammographic breast cancer screening were studied by interviewing a random sample (213 attenders, 121 non-attenders in the 1989 screening) of residents in one of the municipalities of the Florence District Program, where screening has been ongoing since 1970. The overall attendance rate was 60%, and it was dependent on age (40–49 years, 66.5%; 50–59 years, 62.5%; 60–70 years, 55.5%), whereas a significant association with socio-economic status, educational level and health-behavior reported in other programs was not confirmed in the study. This finding suggests that determinants of non-attendance may vary and should be evaluated in each local setting. The belief that screening is useless, fear of cancer being detected, postponement and laziness were the most common motivations of refusal stated by non-attenders, and such a negative attitude towards screening was rather strong since most non-attenders stated they would not like to be informed or stimulated to attend future screenings. Rapid improvement of attendance rates in such a context might be achieved only by putting special pressure on women aimed to change their negative attitude towards screening and their opinion about the benefits of early breast cancer detection. This might be regarded as unacceptable and however would involve high costs and a major organization effort.

Screening History of Incident Cases of Invasive Carcinoma of the Cervix. Florence District 1988-1989

Background

Incident cases of carcinoma of the cervix may be assumed as failures of a population-based cytologic screening program. Monitoring such cases would provide an estimate of screening effectiveness, and evaluating the causes of the failures would improve screening performance.

Study design

All incident cases of cervicocarcinoma registered in 1988 and 1989 in the Tuscany Tumor Registry were eligible for the study and were reviewed.

Results

Sixty-nine eligible cases were considered. Non- or irregular attendance (negative smear-to-diagnosis interval > 5 years) for the Pap smear was recorded in 53 subjects. A false-negative smear (smear-to-diagnosis interval < 5 years) and refused or inadequate assessment/treatment at private practices or local hospitals were recorded in 12 cases. False-negative smears by the local screening program were recorded in 4 cases only.

Conclusions

Non- or irregular attendance was the major cause of screening failures. Since cytologic screening or diagnostic assessment outside the screening program may be inadequate, central screening and follow-up is recommended. Non-attenders showed a strong negative attitude towards screening, and general practitioners and gynecologists need to be further stimulated for systematic screening promotion. Immediate evaluation of the screening history of incident cases of cervicocarcinoma should be mandatory in any screening program.

Trends in the Prevalence of Cervical Intraepithelial Neoplasia Grade 3 in the District of Florence, Italy

Aims and background

The objective of this study was to investigate the detection rate of cervical intraepithelial neoplasia grade III (CIN 3) in previously unscreened women, in order to reveal trends over time in the prevalence of CIN 3 in the District of Florence, where a population-based screening for cervical cancer has been going on since 1973.

Study design

We considered the women, recorded in the computerized archives of CSPO, who had had no pap test for at least 10 years. Trends of CIN 3 (histologically proven) were analyzed within age groups; the effect of age, cohort and period were considered by means of a Poisson regression model.

Results

A total of 648 cases of histologically proven CIN 3 were detected in the study period. The detection rates of CIN 3 increased steadly within age groups over birth cohort and calendar period simultaneously. The Poisson regression analysis showed that only the model with age + time trend was statistically significant.

Conclusions

Although several biases should be taken into account, the analysis seemed to indicate a real increase in CIN 3 prevalence. An increase in frequency of precancerous lesions for cervical cancer in more recent birth cohorts supports the need to keep screening coverage and efficiency as high as possible.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes

OBJECTIVE

The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC).

METHOD

FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant).

RESULTS

In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87).

CONCLUSION

Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

Triage with human papillomavirus testing of women with cytologic abnormalities prompting referral for colposcopy assessment

BACKGROUND

The current study was conducted to evaluate the cost-effectiveness of triaging for colposcopy using human papillomavirus (HPV) testing.

METHODS

HPV tests were performed in a consecutive series of women who were referred for colposcopy for persistent atypical squamous cells of undetermined significance (ASCUS)-favor reactive (n = 35 women), ASCUS-favor squamous epithelial lesion (n = 164 women), atypical glandular cells of undetermined significance (n = 74 women), low-grade squamous epithelial lesion (n = 161 women), or high-grade squamous epithelial lesion (n = 78 women). The cost effectiveness of triaging women with ASCUS results using HPV testing was determined compared with the current protocol.

RESULTS

The sensitivity of HPV testing for cervical intraepithelial neoplasia > Grade 2 was very high. Cost analysis showed a moderate increase in cost with the addition of HPV triage.

CONCLUSIONS

Because HPV testing is highly sensitive, it may be useful as an alternative to the current policy of 6-month repeat cytology for women with ASCUS.

Colorectal cancer screening programme by faecal occult blood test in Tuscany: first round results

Screening with faecal occult blood test (FOBT) has been shown to be effective in reducing mortality from colorectal cancer. Tuscany was the first region in Italy in which a screening programme for colorectal cancer by FOBT was initiated region-wide. The aim of the paper was to describe organizational aspects, a quality control model and the results of this experience. From June 2000 to December 2001, 192583 subjects aged 50-70 were invited to undergo a 1-day immunochemical test without any dietary restriction. A total of 78505 subjects (41%) performed the screening test, of whom 4537 responders had a positive test result (5.8%). Among them, 1122 refused any form of assessment or underwent a colonoscopy outside the screening referral centres, with an overall assessment compliance of 75.3%. Malignancies were found in 193 patients and at least a high-risk adenomatous polyp in 692 patients. In about a quarter of the positive subjects who underwent assessment, cancer or high-risk adenoma was detected. In conclusion, data from this experience supported the feasibility of biennial colorectal screening programme by FOBT, particularly regarding invitation compliance and positivity rate. Further efforts are necessary to implement screening extension and to improve data collection.

The positive experience of screening quality among users of a cervical cancer detection center

BACKGROUND

Our objective was to determine the main factors associated with increased utilization of a cervical cancer screening program (CCSP) in a population with a high mortality rate due to cervical cancer.

METHODS

A population-based study was carried out in the Mexican state of Morelos, Mexico. The study population included 3,197 women between the ages of 15 and 49 years who were selected at random using a State Household Sampling Framework in the State of Morelos's 33 municipalities. The sample included 2,094 women with a history of a previous Papanicolaou (Pap) test.

RESULTS

A previous experience of good screening quality is strongly associated with greater use of the CCSP (OR = 4.2; 95% confidence interval [CI], 1.6-10.9). The educational level of the head of the family is related to more frequent use of Pap smear services. Women whose husbands have 13 or more years of education (OR = 1.8; 95% CI 1.1-2.9) were more likely to have been screened. Similarly, women who had used two or more family planning methods (OR = 1.6; 95% CI 1.2-2.1) and those who knew why the Pap test was given (OR = 3.0; 95% CI 2.1-4.3) had a better history of Pap screening.

CONCLUSIONS

In areas where coverage of cervical cancer screening is low, a CCSP that guarantees the quality of all the different elements of care is essential if obstacles to cervical cancer prevention are to be eliminated. It is of particular importance to take into account and satisfy the perceptions and expectations of the women at risk.

Reasons women do not attend screening for cervical cancer: a population-based study in Sweden

BACKGROUND

With an improved compliance with screening a larger reduction of cervical cancer incidence would be within reach. We aimed at investigating why certain women do not attend Pap smear screening and at validating the reliability of self-reported screening.

METHODS

In 1998 in the county of Uppsala, Sweden, information was collected through telephone interviews with 430 nonattendees and 514 attendees to Pap smear screening, who were all sampled from a population-based database. The women's recall of attendance was validated against the database. The main outcome measures used were odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Non-attendance was positively associated with nonuse of oral contraceptives (OR = 3.56, 95% CI 2.18-5.83), seeing different gynecologists (OR = 1.90, 95% CI 1.34-2.70), and seeing a physician very often (OR = 3.12, 95% CI 1.45-6.70) or not at all (OR = 1.78, 95% CI 1.09-2.90). Frequent condom use (OR = 1.88, 95% CI 1.02-3.47), living in rural/semirural areas (OR = 1.55, 95% CI 1.07-2.21), and not knowing the recommended screening interval (OR = 2.16, 95% CI 1.20-3.89) were all associated with nonattendance, whereas socioeconomic status was not, when tested in a multivariate model. Among the nonattendees, 57% underestimated the time lapse since last smear.

CONCLUSIONS

Seeing a gynecologist on a regular basis and information guiding women to have a Pap smear on their own initiative are important factors for recurrent screening. Therefore, information should be given to all women about the purpose and benefits of Pap smear testing. Self-reports on screening should be treated with caution.

Probability of early repeat Pap smear in an integrated cervical screening programme

The integration of routine Pap smear practice based on self-referral into an organized programme based on personal invitation is the recommended approach to cervical cancer screening. In this study, the cytology archive of the integrated cervical screening programme implemented in the Faenza district (northern Italy) was used to compare the population of women responding to invitation with that of self-referred women for the cumulative probability of early (< 36 months) repeat Pap smear after a negative result. Between 1995 and 1998, women aged 25-64 living in five municipalities of the district were targeted by the first round of the programme. Eligible for the study were 2356 women responding to invitation for screening and 2221 women not invited because of self-referral for Pap smear at any other setting. The probability of early repeat Pap smear was estimated by the life table method. Differences were evaluated by the Gehan test. Multivariate determinants were assessed by the Cox regression analysis. At 36 months' follow-up, the cumulative probability of early repeat Pap smear was 44% among self-referred women and 6% among women responding to invitation (relative hazard = 4.8). For self-referred women, the probability was related to age (with a peak at 35-44 years), previous Pap smear history and municipality of residence. Among women responding to invitation, only an inverse association with age was demonstrated. In conclusion, the observed differences in overall probability and determinants of early repeat Pap smear between the two screening populations provided important information on Pap smear usage in the total target population.

Measurement of the Cost of Screening for Cervical Cancer in the District of Florence, Italy

AIMS AND BACKGROUND

To estimate the cost per woman examined and per CIN II or more severe lesion detected in a population-based cytologic screening program for cervical cancer prevention. An organized cytologic screening program has been ongoing in the Florence District since 1973, and a call-recall system using mail invitation has been ongoing since 1980. Smear reading and assessment of screening positives is centralized at the screening unit.

METHODS AND STUDY DESIGN

All relevant resources (costs) consumed by the program were listed and measured. The unit cost per examined woman and per each CIN II or more severe lesion detected was estimated for each screening phase (recruitment, screening, assessment).

RESULTS

The cost per examined woman was $24.60, whereas that per CIN II or more severe lesion detected was $13,600. Staff accounted for 80% of total amount.

CONCLUSIONS

Although the cost for a single procedure is low, the cost per detected lesion is quite remarkable due to the low detection rate in a population screened for a long time. Different approaches and longer interval screening tests are discussed.