Direct mailing of HPV self-sampling kits to women aged 50-65 non-participating in cervical screening in the Czech Republic

BACKGROUND

A population-based cervical cancer screening programme is implemented in the Czech Republic. However, participation is insufficient among women over 50 years. This study aimed to estimate the potential improvement in participation through directly mailed HPV self-sampling kits (HPVssk) compared with standard invitation letters in women aged 50-65 non-participating in screening.

METHODS

The study recruited 1564 eligible women (no cervical cancer screening in the last 3 years or more, no previous treatment associated with cervical lesions or cervical cancer). Eight hundred women were mailed with an HPVssk (HPVssk group), and 764 women were sent a standard invitation letter (control group) inviting them to a routine screening (Pap test). The primary outcome was a comparison of the overall participation rate between study groups using a binominal regression model.

RESULTS

The participation rate in the HPVssk group was 13.4% [95% confidence interval (CI) 11.2-15.9%; 7.4% of women returned the HPVssk and 6.0% attended gynaecological examination] and 5.0% (95% CI 3.6-6.8%) in the control group. Using the binominal regression model, the difference between the groups was estimated as 7.6% (95% CI 5.0-10.2%; P < 0.001). In the HPVssk group, 22% of women who returned HPVssk had a positive result and 70% of them underwent a follow-up examination.

CONCLUSIONS

Compared with traditional invitation letters, the direct mailing of the HPVssk achieved a significantly higher participation rate, along with a notable HPV positivity rate among HPVssk responders. This approach offers a potentially viable method for engaging women who have not yet attended a cervical screening programme.

How to follow the new EU Council recommendation and improve prostate cancer early detection: the Prostaforum 2022 declaration

An updated Council of the EU recommendation on cancer screening was adopted in December 2022 during the Czech EU presidency. The recommendation included prostate cancer as a suitable target disease for organised screening, and invited countries to proceed with piloting and further research. To support further discussions and actions to promote early detection of prostate cancer, an international conference in November 2022 (Prostaforum 2022) resulted in a joint declaration. Here we describe the EU policy background, summarise the preparation of the declaration and the key underlying evidence and expert recommendations, and report the text of the declaration. The declaration summarises the striking inequalities in prostate cancer burden in Europe and calls on all stakeholders to consider and support concrete steps for advancement of organised early detection of prostate cancer. Our aim is to request endorsement of the text and potential initiation of practical actions by all stakeholders to support the aims of the declaration.

Patient summary

Prostate cancer is among the most frequent cancers and is one of the most common causes of cancer death among men. The European Union has recommended new pilot programmes for prostate cancer screening. The Prostaforum 2022 declaration invites all stakeholders to support this new recommendation with specific steps.

Coverage by examinations associated with early detection of colorectal neoplasia in the Czech Republic

BACKGROUND

Coverage by examinations is a crucial indicator of the future impact on the burden of colorectal cancer (CRC). The study aimed to evaluate coverage by examinations associated with CRC screening and early cancer detection of CRC in the Czech Republic. The burden of CRC was also assessed.

METHODS

The novel nationwide administrative registry with individual data (period 2010-19) was used to evaluate coverage by examinations for screening faecal occult blood test and colonoscopy. In the second step, additional examinations for early CRC detection were included in the coverage calculation (complete coverage). Age-specific trends in CRC incidence (period 1977-2018) were investigated using Joinpoint regression.

RESULTS

Coverage by screening examinations within recommended interval was around 30%. Complete coverage reached >37% and >50% at the 3-year interval. The coverage by examinations for the non-screening population aged 40-49 years was almost 4% and 5% (most of them were colonoscopies) at the 3-year interval. In age groups aged ≥50 years, we observed a significant annual decline, especially in the 50-69 age group, with recent annual decreases reaching up to 5-7%. The change in trend and the recent decline were also observed in the age group 40-49.

CONCLUSIONS

More than half of the target screening population was covered by examinations potentially associated with early detection and subsequent treatment of colorectal neoplasms. The substantial coverage by potentially prophylactic examinations might be an explanation for the considerable decrease in CRC incidence.

Complete coverage by examinations: relationship to colorectal cancer burden and the COVID-19

Background

Colorectal cancer (CRC) is among the most common cancers and cancer causes of death worldwide. CRC screening and early detection is essential to reduce CRC incidence and mortality. CRC screening has been initiated in the Czech Republic in 2000 for persons over 50 and currently offers a faecal occult blood test (FOBT) or screening colonoscopy (CS). The aim of our study was to present complete coverage by examinations in relation to the trends in CRC burden and impact of COVID-19.

Methods

We defined the complete coverage by examinations as the proportion of persons aged over 50 undergoing examination with CRC early detection potential (FOBT or CS for any indication) during past 3 years. Standardized incidence and mortality rates were used to assess epidemiological trends. The impact of COVID-19 was assessed for 2020 and 2021 by comparing the volume of examinations with 2019. We used national health registries (National Registry of Reimbursed Health Services, Czech National Cancer Registry) as the source of data.

Results

Complete coverage was increasing over time and reached around 50% in recent years (target population is more than 4 million persons, most of the performed examinations were screening FOBT). However, coverage has decreased to 47.9% in 2020. In 2020 and 2021, the number of tests performed decreased by 16.9% and 5.5%, respectively, compared to 2019. CRC incidence and mortality rates have decreased by more than 20% and almost 30%, respectively, in the last decade.

Conclusions

Complete coverage has reached a satisfactory level and has likely a positive impact on the epidemiological trends. However, further action is needed to increase coverage, recently affected by COVID-19 pandemic, when non-acute health care may have been neglected.

Key messages

• The long-term high level of coverage by examinations likely has a positive impact on CRC burden.

• The observed decrease in coverage caused by COVID-19 needs to be appropriately compensated.

Potential gains by effective early detection of diseases: proposal to approach informing public health policy in the Czech Republic

Background

Significant amount of disease burden could be averted by early detection and treatment of diseases. In the Czech Republic, National Screening Centre (NSC) of the Institute of Health Information and Statistics is responsible for informing public health policy in the field of early disease detection. The objective of the proposed early detection public health foresight study (PHFS) is to gather evidence, use available computational tools, utilise knowledge and opinions of stakeholders, and summarize it in a systematic manner to inform public health policies. The presentation outlines the approach undertaken within the proposed early detection PHFS.

Methods

The key source of data for monitoring of population health status and healthcare system in the Czech Republic is the National Health Information System (NHIS). The study will also utilise external sources of data, namely demographic projections and data on global burden of disease, as well as qualitative data from stakeholders. The study will also utilise analytical tools and outputs developed by NSC (situational analyses, decision modelling, etc.). The conceptual model of the study will cover important underlying aspects like public policies, driving forces, population health and healthcare system, and health impact variables.

Results

The proposal for early detection PHFS has been developed within the PHFS capacity building course, utilising the experience and insights of tutors and fellow participants. The development of study methodology was accompanied by gathering of evidence and consultations with relevant stakeholders.

Conclusions

PHFS is a very useful approach to assess possible future developments of public health system, achieve participation of stakeholders, and to inform public health strategies. Following finalisation of the early detection PHFS protocol, governing board of the NSC will decide on the degree of implementation of the study.

Somatic Mutations in Exon 7 of the TP53 Gene in Index Colorectal Lesions Are Associated with the Early Occurrence of Metachronous Adenoma

Simple Summary

Identifying patients with an increased risk of early recurrence of colorectal lesions is still a problem. In our study, we focused on improving this identification by determining the mutation profile of index lesions. We found a statistically significant association between the mutation in exon 7 of the TP53 gene in the index lesion and the risk of early metachronous adenoma.

Abstract

(1) Background: this prospective study was focused on detailed analysis of the mutation heterogeneity in colorectal lesions removed during baseline (index) colonoscopy to identify patients at high risk of early occurrence of metachronous adenomas. (2) Methods: a total of 120 patients after endoscopic therapy of advanced colorectal neoplasia size ≥10 mm (index lesion) with subsequent surveillance colonoscopy after 10–18 months were included. In total, 143 index lesions and 84 synchronous lesions in paraffin blocks were divided into up to 30 samples. In each of them, the detection of somatic mutations in 11 hot spot gene loci was performed. Statistical analysis to correlate the mutation profiles and the degree of heterogeneity of the lesions with the risk of metachronous adenoma occurrence was undertaken. (3) Results: mutation in exon 7 of the TP53 gene found in the index lesion significantly correlated with the early occurrence of metachronous adenoma (log-rank test p = 0.003, hazard ratio 2.73, 95% confidence interval 1.14–6.56). We did not find an association between the risk of metachronous adenomas and other markers monitored. (4) Conclusions: the findings of this study could lead to an adjustment of existing recommendations for surveillance colonoscopies in a specific group of patients with mutations in exon 7 of the TP53 gene in an index lesion, where a shortening of surveillance interval may be warranted.

Invitation of non-attenders to colorectal cancer screening: impact on coverage by examination

Issue

Colorectal cancer (CRC) has been among the most important cancer causes of death globally. CRC screening and early detection can decrease CRC incidence and mortality through timely removal of colorectal neoplasia or early CRC treatment. CRC screening has been initiated in the Czech Republic in 2000 for individuals over 50, with GPs having a key role in recruiting individuals to screening, offering faecal occult blood test (FOBT). Screening colonoscopy (CS) was added for individuals over 55 since 2009.

Description of the problem

To increase uptake of CRC screening, personal invitation of non-attenders under 70 was implemented in 2014, along with temporary mass-media campaign. Health insurance companies have been sending invitations to those individuals without record of recent FOBT, CS or CRC treatment.

The aim of our study was to evaluate impact of this policy on complete coverage by examination over 2013-2018. We defined the complete coverage by examination as the proportion of individuals aged 50-69 undergoing examination with CRC early detection potential (FOBT or CS for any indication) during past 3 years. We used newly established National Registry of Reimbursed Health Services as the source of data.

Results

Complete coverage of the target population (2.7 million individuals aged 50-69) was 44.8 % in 2013. By 2016, the coverage increased to 54.6%. Therefore, almost 300,000 individuals were newly covered by the relevant examinations. By 2018, the coverage decreased to 51.2%. When we consider only screening FOBT examinations, the coverage was 36.9 % in 2013, 45.2% in 2016, and 42.0% in 2018.

Lessons

In the health system with accessible CS facilities, the policy of non-attenders' invitation for CRC screening resulted not only in increase in coverage by screening examinations; complete coverage also increased. Unfortunately, the positive effect has been fading out, and further actions to sustain high coverage are therefore warranted.

Key messages

Invitation of non-attenders to colorectal cancer screening increased complete coverage of the target population by examination. Initial increase was followed by a slow decrease in coverage by examination, underlying the need for other actions to increase participation.

Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years

OBJECTIVE

The incidence of colorectal cancer (CRC) declines among subjects aged 50 years and above. An opposite trend appears among younger adults. In Europe, data on CRC incidence among younger adults are lacking. We therefore aimed to analyse European trends in CRC incidence and mortality in subjects younger than 50 years.

DESIGN

Data on age-related CRC incidence and mortality between 1990 and 2016 were retrieved from national and regional cancer registries. Trends were analysed by Joinpoint regression and expressed as annual percent change.

RESULTS

We retrieved data on 143.7 million people aged 20-49 years from 20 European countries. Of them, 187 918 (0.13%) were diagnosed with CRC. On average, CRC incidence increased with 7.9% per year among subjects aged 20-29 years from 2004 to 2016. The increase in the age group of 30-39 years was 4.9% per year from 2005 to 2016, the increase in the age group of 40-49 years was 1.6% per year from 2004 to 2016. This increase started earliest in subjects aged 20-29 years, and 10-20 years later in those aged 30-39 and 40-49 years. This is consistent with an age-cohort phenomenon. Although in most European countries the CRC incidence had risen, some heterogeneity was found between countries. CRC mortality did not significantly change among the youngest adults, but decreased with 1.1%per year between 1990 and 2016 and 2.4% per year between 1990 and 2009 among those aged 30-39 years and 40-49 years, respectively.

CONCLUSION

CRC incidence rises among young adults in Europe. The cause for this trend needs to be elucidated. Clinicians should be aware of this trend. If the trend continues, screening guidelines may need to be reconsidered.

Evaluation of the personalized invitation of Czech citizens to screening programs

The Czech population has high burden of malignant tumors, and screening programs are therefore an essential part of cancer control policy. At the beginning of 2014 personalized invitation of Czech citizens for cancer screening programs was launched to promote higher coverage by screening. The aim of the paper is to present the up-to-date results of the personalized invitation. The data from health insurance companies were used to evaluate the volume of invitations for cancer screening programs and the participation rate after invitation in 2014-2017. During the first four years of the project, over 6 million invitations were sent (approximately 3 million individuals were invited). Participation rates after the first invitation in the breast, colorectal and cervical screening were 22.3%, 21.7% and 15.5%. However, the effect of personalized invitations decreases with repeated invitations to participate. Personalized invitation contributed to screening in hundreds of thousands citizens, but a large proportion of invited people still do not participate. It is necessary to encourage personalized invitation and discuss other strategies to motivate the public to participate in screening programs.

[Population colorectal cancer screening in the Czech Republic]

Colorectal cancer (CRC) is the third most common malignant disease in developed countries and its incidence is steadily growing. This trend has a stable character despite the fact that CRC is among the best prevention influenced malignancies. National CRC screening program in the Czech Republic, which was established in year 2000, follows the world trends resulting from evidence based medicine. Currently, the basic tools of screening program are immunochemical fecal occult blood tests and colonoscopy in case of their positivity or screening colonoscopy. Stagnation of participating population resulted to initiation of address invitation of the target population in January 2014, in which citizens are regularly invited to attend the screening program and their response is subsequently evaluated. Screening that impacts whole target group is called population screening.

KEY WORDS

colorectal cancer, population screening program, colonoscopy, fecal occult blood tests, address invitation.

[Performance indicators in screening programmes]

Breast, colorectal and cervical cancer screening programmes make it possible to decrease the population mortality rates of these diseases. How-ever, complex standards of the quality of care must be introduced and followed in order to maintain a favourable ratio between the benefits and risks arising from population-wide screening programmes. Such programmes should be organized and population-based, ensuring that quality control is performed at all levels. This review introduces the system of quality control in the Czech cancer screening programmes, and provides specific examples of performance indicators that are usable and/ or being used in these programmes. Cancer screening programmes in the Czech Republic are equipped with a comprehensive information background which involves monitoring of the cancer burden in the population, monitoring of the screening process based on clinical data, and monitoring of the screening process based on administrative data. In particular, the specific performance indicators describe the success rate of take up of the target population, ability of the screening test to reveal (sensitivity) or to exclude (specificity) the screened condition, correct employment of subsequent diagnostic methods or treatment of detected cancers or precancerous lesions where applicable. In the Czech breast cancer screening programme, these indicators are routinely used in order to monitor the individual centres; in both colorectal and cervical cancer screening programmes, these indicators are used to monitor the entire programme, whereas the system of quality control for individual centres is under continuous development. A project of personalized invitations was launched in 2014, and its results are regularly evaluated in cooperation with the Czech National Reference Centre and the Ministry of Health of the Czech Republic.

[Results of the Czech National Colorectal Cancer screening programme - faecal occult blood tests]

INTRODUCTION

The nationwide Colorectal Cancer Screening Programme was introduced in the Czech Republic in 2000. The aim of this article is to describe the employment of faecal occult blood tests (FOBTs) by the Czech population within the screening programme, and to provide information on the latest results of the programme.

MATERIAL AND METHODS

Data on the development of the colorectal cancer (CRC) burden in the Czech population is obtained from the Czech National Cancer Registry, a database required by the Czech law that has been collecting comprehensive data on cancer patients since 1977. Data on FOBT employment can be obtained from health care payers, and was provided by the Czech National Reference Centre.

RESULTS

Around 8,000 patients are diagnosed with colorectal cancer in the Czech Republic each year, and the number of CRC deaths is about 4,000. Despite the ongoing screening programme, significant improvements in the proportional representation of cancer stages (i.e., improvements in early detection of CRC cases) have yet to be seen. Although the number of FOBTs performed in the Czech Republic has significantly grown in the long term (which is accompanied by an increase in coverage by this screening test), the total coverage of the Czech population aged over 50 was only 25.5% in 2012. The Olomouc Region, the Zlin region, and the Usti nad Labem region had the highest coverage rates by CRC screening based on FOBT (over 28%), while the Capital of Prague had the lowest coverage rate (18%). Since 2008, FOBT positivity rates have seen a continuous and significant increase, reaching 6.9% in 2012. Between 13 to 14% of FOBTs in women are performed by practical gynaecologists.

CONCLUSION

Despite a significant increase in the participation rate in recent years, which was partially improved by the involvement of practical gynaecologists, the programme unfortunately still covers only a quarter of the eligible population. Implementation of effective measures aimed at getting people interested in preventive examinations (including the recently introduced programme of personalized invitations) is therefore essential; otherwise, the screening programme will not be successful on the population level.

[Results of the Czech National Breast Cancer screening programme]

INTRODUCTION

Breast cancer screening based on mammography is an effective tool for lowering mortality rates from this disease. The organised and nationwide Breast Cancer Screening Programme has been underway in the Czech Republic since 2002.

MATERIAL AND METHODS

Monitoring of the programme is based on data from the Czech National Cancer Registry (CNCR), Breast Cancer Screening Registry, and the Czech National Reference Centre (CNRC). These data sources make it possible to evaluate early performance indicators according to international standards, and to monitor the cancer burden in the Czech population. The CNRC data allow us to document the high validity of the available data as well as to map non-organised mammography examinations (so-called opportunistic screening).

RESULTS

Until the mid-1990s, breast cancer incidence and mortality rates saw a slight but continuous increase. In the last 15 years, however, incidence rates have grown more substantially; by contrast, mortality rates have stalled and even started to decline since the 2000s. In the mid-1990s, the proportion of cancers diagnosed at stage I was below 20%; this situation has dramatically improved since then, as more than 40% cases of breast cancer were diagnosed at stage I in 2011. Breast cancer screening coverage currently amounts to 50%; this value reached a plateau in the period 2007-2008, and unfortunately has not shown any further significant increase.

CONCLUSION

Over the last few decades, the breast cancer burden among the Czech population has been significantly reduced - despite the growing incidence rates, mortality rates have decreased, which can be largely attributed to earlier detection of breast cancer based on the screening programme. Further improvements in the programmes effectiveness can only be achieved if the population coverage becomes higher; the programme of personalised invitations to mammography examinations, which was introduced in early 2014, should contribute to the accomplishment of this goal.

[Results of the Czech National Colorectal Cancer Screening Programme - colonoscopy examinations]

INTRODUCTION

Colorectal cancer (CRC) is one of the most common cancers, and the Central European countries have the highest CRC burden worldwide. CRC screening has repeatedly been proven capable of decreasing CRC mortality and incidence rates. The nationwide Colorectal Cancer Screening Programme in the Czech Republic involves the colonoscopic examination as a diagnostic method (for patients with a positive FOBT result -  screening colonoscopy -  SC), or as a screening method (primary screening colonoscopy -  PSC). The aim of this article is to present the results of colonoscopic examinations performed as part of the Czech screening programme.

MATERIAL AND METHODS

For the purpose of quality assurance, the Czech programme has been equipped since 2006 with an information system called the Colorectal Cancer Screening Registry, which collects and evaluates data on preventive colonoscopies performed in the colonoscopy screening centres. Performance indicators, as specified in the European Guidelines (and adapted for the Czech programme), are employed to assess preventive colonoscopies performed in the Czech Republic.

RESULTS

Since 2006, more than 110,000 SCs and almost 20,000 PSCs were recorded. Approximately 95% of SCs and almost 98% of PSC were classified as total, i.e. examining the entire colonic mucosa up to the caecum. The positive predictive value of FOBT for adenomas has increased slightly and continuously over time, and was 39.7% in 2013. In PSC, the adenoma detection rate (ADR) has recently increased compared to previous years, and was 27.3% in 2013. CRC was detected in 3.7% of individuals undergoing an SC examination and in 1.0% of individuals undergoing a PSC examination. The programme safety is controlled based on the monitoring of complications during colonoscopies; these can occur either during diagnostic colonoscopy (perforation in 0.03% of cases since 2006) or during endoscopic polypectomy (perforation in 0.12% of cases, bleeding in 0.73% of cases since 2006).

CONCLUSION

Our results confirm that the quality of colonoscopic examinations corresponds to the international standards and that this is not an obstacle to a positive impact of CRC screening on the Czech population, which has a high colorectal cancer burden.