Sisse Helle Njor

Indicators to identify cancer screening providers with suboptimal case detection: A scoping review

Abstract Several international guidelines consider sensitivity (of test, episode, or programme) and related measures of the detection of prevalent cases of target disease to be among key performance indicators for quality control of routine cancer screening programmes and use them to identify suboptimal providers. We aimed to describe the variability encountered in real‐world settings around the measurement of these quantities in cervical and colorectal cancer screening, where the target for disease detection includes preinvasive disease. We performed a scoping review of grey literature, including international guidelines, annual statistical reports, and other official documents from European cervical and colorectal screening programmes. From the reviewed material, we extracted information on 20 measures used for this purpose. Some measures have been adopted in several programmes, but none have been used in all, not even within the same cancer type. While many of the methods might appear plausible for the intended use, our analysis showed that when applied to routinely collected data they may provide misleading or uninterpretable estimates of the ability of individual providers and the service as a whole to detect prevalent cases. Screening programmes should be cautious in their choice and interpretation of these measures. Further methodological development is required to better support policymakers and quality control managers in prioritising measures that are fit for purpose in routine cancer screening programmes.

Increasing coverage in cervical and colorectal cancer screening by leveraging attendance at breast cancer screening: A cluster-randomised, crossover trial

Background Screening participation remains suboptimal in cervical cancer (CC) and colorectal cancer (CRC) screening despite their effectiveness in reducing cancer-related morbidity and mortality. We investigated the effectiveness of an intervention by leveraging the high participation rate in breast cancer (BC) screening as an opportunity to offer self-sampling kits to nonparticipants in CC and CRC screening. Methods and findings A pragmatic, unblinded, cluster-randomised, multiple period, crossover trial was conducted in 5 BC screening units in the Central Denmark Region (CDR) between September 1, 2021 and May 25, 2022. On each of 100 selected weekdays, 1 BC screening unit was randomly allocated as the intervention unit while the remaining units served as controls. Women aged 50 to 69 years attending BC screening at the intervention unit were offered administrative check-up on their CC screening status (ages 50 to 64 years) and CRC screening status (aged 50 to 69), and women with overdue screening were offered self-sampling. Women in the control group received only standard screening offers according to the organised programmes. The primary outcomes were differences between the intervention group and the control group in the total screening coverage for the 2 programmes and in screening participation among women with overdue screening, measured 6 months after the intervention. These were assessed using intention-to-treat analysis, reporting risk differences with 95% confidence intervals (CIs). A total of 27,116 women were included in the trial, with 5,618 (20.7%) in the intervention group and 21,498 (79.3%) in the control group. Six months after the intervention, total coverage was higher in the intervention group as compared with the control group in CC screening (88.3 versus 83.5, difference 4.8 percentage points, 95% CI [3.6, 6.0]; p < 0.001) and in CRC screening (79.8 versus 76.0, difference 3.8 percentage points, 95% CI [2.6, 5.1]; p < 0.001). Among women overdue with CC screening, participation in the intervention group was 32.0% compared with 6.1% in the control group (difference 25.8 percentage points, 95% CI [22.0, 29.6]; p < 0.001). In CRC screening, participation among women overdue with screening in the intervention group was 23.8% compared with 8.9% in the control group (difference 14.9 percentage points, 95% CI [12.3, 17.5]; p < 0.001). Women who did not participate in BC screening were not included in this study. Conclusions Offering self-sampling to women overdue with CC and CRC screening when they attend BC screening was a feasible intervention, resulting in an increase in participation and total coverage. Other interventions are required to reach women who are not participating in BC screening. Trial registration ClinicalTrials.gov NCT05022511. The record of processing activities for research projects in the Central Denmark Region (R. No.: 1-16-02-217-21).

Adherence to follow‐up after the exit cervical cancer screening test at age 60–64: A nationwide register‐based study

AbstractBackgroundIn Denmark, human papillomavirus (HPV) testing has replaced cytology in primary cervical cancer screening for women aged 60–64; at this age, women are invited for the last (exit) screening test within the national organized program.AimWe investigated the adherence of these women to the recommended follow‐up after a non‐negative (positive or inadequate) HPV test and the overall resource use during that follow‐up.Materials & MethodsWe included all 2926 women aged 60–64 years with nonnegative HPV screening tests between March 2012 and December 2016. All relevant follow‐up tests and procedures were retrieved until the end of 2020 from the highly complete Danish administrative health registers, and the data were linked at the individual level. We determined the extent to which the adherence patterns followed the national recommendations for follow‐up and estimated the total numbers of tests and diagnostic procedures utilized during the entire process.ResultsIn total, only 26% of women had follow‐up in accordance with the recommendations; 4% had no follow‐up, 46% had insufficient follow‐up, and 24% had more follow‐up than recommended. We estimated that 17% of women remained in follow‐up for longer than 4 years. The average numbers of diagnostic tests and procedures used after positive HPV screening were higher than expected, even among women who had insufficient follow‐up, that is, those who received less invasive procedures than recommended, or experienced delays in receiving those procedures.ConclusionTo conclude, we found that the patterns of follow‐up of women with nonnegative primary HPV screening tests at 60–64 often diverged from the recommendations. Addressing these inconsistencies in follow‐up by providing evidence for optimal clinical management should help improve the quality of screening programs and secure an equal and reliable follow‐up care service for all women.

Widening the offer of human papillomavirus self‐sampling to all women eligible for cervical screening: Make haste slowly

AbstractSelf‐collection of samples for human papillomavirus (HPV) testing has the potential to increase the uptake of cervical screening among underscreened women and will likely form a crucial part of the WHO's strategy to eliminate cervical cancer by 2030. In high‐income countries with long‐standing, organised cervical screening programmes, self‐collection is increasingly becoming available as a routine offer for women regardless of their screening histories, including under‐ and well‐screened women. For these contexts, a validated microsimulation model determined that adding self‐collection to clinician collection is likely to be cost‐effective on the condition that it meets specific thresholds relating to (1) uptake and (2) sensitivity for the detection of high‐grade cervical intraepithelial neoplasia (CIN2+). We used these thresholds to review the ‘early‐adopter’ programme‐level evidence with a mind to determine how well and how consistently they were being met. The available evidence suggested some risk to overall programme performance in the situation where low uptake among underscreened women was accompanied by a high rate of substituting clinician sampling with self‐collection among well‐screened women. Risk was further compounded in a situation where the slightly reduced sensitivity of self‐sampling vs clinician sampling for the detection of CIN2+ was accompanied with lack of adherence to a follow‐up triage test that required a clinician sample. To support real‐world programmes on their pathways toward implementation and to avoid HPV self‐collection being introduced as a screening measure in good faith but with counterproductive consequences, we conclude by identifying a range of mitigations and areas worthy of research prioritisation.

Three Birds With One Stone

The overall aim of the study is to increase participation rates in cervical cancer (CCU) and colorectal cancer (CRC) screening programmes in Denmark by offering home-based CCU and CRC screening to women who are overdue for one or both screening programmes when attending breast cancer screening