Journal of Medical Screening

Decline in breast cancer mortality: How much is attributable to screening?

Objectives When estimating the decline in breast cancer mortality attributable to screening, the challenge is to provide valid comparison groups and to distinguish the screening effect from other effects. In Funen, Denmark, multidisciplinary breast cancer management teams started before screening was introduced; both activities came later in the rest of Denmark. Because Denmark had national protocols for breast cancer treatment, but hardly any opportunistic screening, Funen formed a “natural experiment”, providing valid comparison groups and enabling the separation of the effect of screening from other factors. Methods Using Poisson regression we compared the observed breast cancer mortality rate in Funen after implementation of screening with the expected rate without screening. The latter was estimated from breast cancer mortality in the rest of Denmark controlled for historical differences between Funen/rest of Denmark. As multidisciplinary teams were introduced gradually in the rest of Denmark from 1994, the screening effect was slightly underestimated. Results Over 14 years, women targeted by screening in Funen experienced a 22% (95% confidence interval 11%–32%) reduction in breast cancer mortality associated with screening (a reduction in breast cancer mortality rate from 61 to 47 per 100,000). The estimated reduction for participants corrected for selection bias was 28% (13%–41%). Excluding deaths in breast cancer cases diagnosed after end of screening, these numbers became 26% and 31%, respectively. Conclusions There is additional benefit in reducing breast cancer mortality from the early detection of breast cancer through mammographic screening over and above the benefits arising from improvements in treatment alone.

Is it feasible to enhance quality assurance of cervical cancer screening in Latin America? A regional expert consensus

Objectives Cervical cancer elimination requires high-performance screening tests and high treatment rates, and thus high screening program performance is essential; however, Latin America lacks organized screening and quality assurance (QA) guidelines. We aimed to develop a core set of QA indicators suitable to the region. Methods We reviewed QA guidelines from countries/regions with highly organized screening programs and selected 49 indicators for screening intensity, test performance, follow-up, screening outcomes and system capacity. A regional expert consensus using the Delphi method in two rounds was implemented to identify basic indicators actionable within the regional context. The panel was integrated by recognized Latin American scientists and public health experts. They voted for the indicators blinded to each other based on feasibility and relevance. The correlation between both attributes was analyzed. Results In the first round 33 indicators reached consensus for feasibility but only 9 for relevance, without full coincidence. In the second round 9 indicators met the criteria for both (2 screening intensity, 1 test performance, 2 follow-up, 3 outcomes, 1 system capacity). A significant positive correlation was observed for test performance and outcomes indicators between the two attributes assessed ( p < 0.05). Conclusions Cervical cancer control requires realistic goals supported by proper programs and QA systems. We identified a set of indicators suitable to improve cervical cancer screening performance in Latin America. The assessment by an expert panel with a joint vision from science and public health practice represents a significant progress towards real and feasible QA guidelines for countries in the region.

Investigating the acceptability of cervical screening, using conventional clinician-taken cervical samples or urine self-sampling, at 6 weeks postnatal: A cross-sectional questionnaire

Objectives United Kingdom (UK) guidelines recommend delaying cervical screening due during pregnancy to 12 weeks postnatal, despite a lack of supporting evidence. This questionnaire-based study aimed to determine the feasibility of a clinical study of cervical screening and urine self-sampling for human papillomavirus (HPV) at 6 weeks postnatal, as pilot work suggested this would improve uptake, if offered at the routine postnatal check-up. Methods Females who were pregnant/recently pregnant were invited to participate in a web-based questionnaire. Questions assessed acceptability of postnatal cervical screening at 6 weeks postnatal, analysed with chi-square, Fisher's exact and Mann–Whitney tests. Free-text responses were coded using the Theoretical Framework of Acceptability (TFA) to conduct a qualitative content analysis. Results Among the 454 participants, 266 (58.6%) would be more likely to undergo cervical screening if offered at 6 weeks postnatal, and an even higher proportion expressed increased willingness if urine self-sampling were offered ( n  = 338; 74.4%). Two-thirds (308/454; 67.8%) would be willing to be screened at 6 weeks postnatal for a research study and 356/454 (78.4%) if it would be limited only to urine self-sampling. When considering screening modality, over half (245/454; 54%) would prefer urine self-sampling to cervical screening, although a fifth (93/454; 21%) preferred conventional sampling. Free-text responses were provided by 279 participants, and these highlighted that affective attitude and burden TFA constructs underpinned prospective acceptability of having screening at 6 weeks postnatal. Conclusions Offering cervical screening at the 6-week postnatal check-up has potential to increase cervical screening participation. Most participants would be interested in taking part in the research. The feasibility of screening at 6 weeks postnatal and concurrent acceptability should be tested in pilot clinical studies.

How follow-up rates in cervical cancer screening depend on organizational factors: A comparison of two population-based organized screening programmes

Objectives This study compares the follow-up rates of non-normal cervical screening samples between Denmark and Flanders (Belgium) to illuminate whether organizational differences between the health systems might affect the follow-up rates, e.g. sending of reminders in Denmark since 2012 compared to Flanders with no such system in place. Methods The study population included 48,082 Danish women and 22,271 Flemish women who received abnormal or inadequate primary screening results from 2014 to 2016. The participants were followed for 24 months, and the timeliness and appropriateness of the recommended follow-up, according to national guidelines, were evaluated. Results After 18 months over 90% of the Danish women had received some form of follow-up, while in Flanders, this level is achieved only for those who test positive for human papillomavirus. The analysis also revealed that 10–28% of follow-ups were performed too early, with Danish women showing the highest proportions. In both regions, general practitioners (GPs) exhibited better follow-up rates compared to gynaecologists, with gynaecologists displaying a tendency towards earlier re-testing than recommended. Conclusions An important factor influencing the follow-up rate may be the sending of reminders in Denmark since 2012, as the follow-up rates in general were higher in this period. It is noteworthy that a reminder system is currently being implemented in Flanders and further studies on the potential effects should be studied. Additionally, the organization of the health system might influence the follow-up rate, as engaging the GP for screening in Denmark may have had a positive effect.

The impact of age at initial HPV vaccination on cervical cancer screening participation in a nationally representative cohort of women in the United States

Objective A better understanding of factors associated with cervical cancer screening can inform strategies for cervical cancer prevention. This study examined the relationship between age at human papillomavirus (HPV) vaccination and participation in cervical cancer screening among a nationally representative sample of women in the United States. Methods We utilized data from the National Survey of Family Growth for the years 2015–2019 focusing on women aged 18–24 vaccinated against HPV. Age at first HPV immunization was analyzed as both a dichotomous (vaccinated at 9–12 vs. 13–23 years) and a continuous variable. The outcome measured was ever having a Pap smear. Multivariable logistic regression that accounted for complex survey design was employed to estimate adjusted prevalence ratios and differences from average marginal predictions. Results The study comprised 981 individuals, representing 6.05 million women. Over half of the study population had a Pap test (57.4%). Women vaccinated at ages 9–12 were less likely to participate in screening compared to those vaccinated at ages 13–23 [risk difference: −9.1, 95% confidence interval (CI) −16.7 to −1.5)] which translates into 120,260 fewer women nationwide getting cervical cancer screening. Each 1-year increase in age at first vaccination was associated with a 1.1% (95% CI, −0.1 to 2.4%) higher probability of having a Pap test, but this linear trend was not statistically significant. Conclusions Our study underscores the importance of promoting cervical cancer screening not only among unvaccinated women but also among those who received the HPV vaccine at the recommended ages of 9–12.

Identifying optimum implementation for human papillomavirus self-sampling in underserved communities: A systematic review

Objective To review the existing evidence to identify the optimum methods for implementing human papillomavirus self-sampling to increase screening uptake for underserved groups. Setting Specific groups are less likely to participate in cervical screening. These include individuals from low socioeconomic status groups, ethnic minority groups, younger age groups (25–29), older age groups (≥50), with a physical disability, with a learning disability and with an LGBTQ+ identity. The advent of human papillomavirus self-sampling for cervical screening presents an opportunity to promote equitable access to screening. Implementation for human papillomavirus self-sampling can vary, for example, opt-out or opt-in approaches. However, it is unclear which of these is the best method of offering human papillomavirus self-sampling to underserved groups. Methods Six databases were searched through May 2023. Studies comparing cervico-vaginal human papillomavirus self-sampling provision using different implementation strategies with the standard screening pathway in underserved groups were identified. A narrative synthesis was conducted. Results In total, 4574 studies were identified; 25 studies were included, of which 22 were from high-income countries. Greater uptake was found for offering human papillomavirus self-sampling compared to standard clinician-based sampling. Directly mailing human papillomavirus self-sampling kits to participants resulted in higher uptake of screening than using an ‘opt-in’ approach or standard recall in low socioeconomic status and ethnic minority groups, and older women. Strategies that used community health workers or educational materials increased uptake in ethnic minority and low socioeconomic status groups. Conclusions Directly mailing human papillomavirus self-sampling kits to low socioeconomic status groups, ethnic minority groups and older women has the potential to increase uptake of human papillomavirus self-sampling. Using community health workers to offer human papillomavirus self-sampling should be considered for ethnic minority and low socioeconomic status groups. Further research exploring the preferences of younger women is needed.

Attitudes towards being offered a choice of self-sampling or clinician sampling for cervical screening: A cross-sectional survey of women taking part in a clinical validation of HPV self-collection devices

Objectives Primary human papillomavirus (HPV) testing in cervical screening offers the opportunity for women to be given a choice between HPV self-sampling and traditional clinician screening. This study assessed attitudes towards a choice and anticipated future preference among women who had collected a vaginal self-sample alongside their usual cervical screen. Setting Thirty-eight general practices across five areas in England. Methods Overall, 2323 women (24–65 years; response rate: 48%) completed a survey after collecting a self-sample and having a clinician screen at their GP practice. We asked which test they preferred and assessed attitudes to being offered a choice. We explored age, education, ethnicity and screening experience as predictors of attitudes towards a choice and anticipated future choice. Results Most participants felt they would like a choice between self-sampling and clinician screening (85%) and thought this would improve screening for them (72%). However, 23% felt it would be difficult to choose, 15% would worry about making a choice, and nearly half would prefer a recommendation (48%). Compared with women with degree-level education, those with fewer qualifications were more likely to say they would worry about having a choice or would not want a choice (p < 0.001). The majority said they would choose to self-sample at home if offered a choice in the future (69%; n = 1602/2320). Conclusions Self-sampling is likely to be popular, but offering a choice could cause worry for some people and many would prefer a recommendation. Supporting people to make a choice will be important, particularly for those with lower levels of education.

Disparities in the use of regular pap smears among migrant and non-migrant women in Austria: A population-based survey of 7633 women

Objective: Regular pap smears are effective in reducing cervical cancer incidence and mortality. Migrant women have been reported to utilize cervical cancer screening less often than non-migrant women. However, inconsistent results, e.g. from Germany, have also been reported. This study examines disparities in the use of annual pap smears among 20–69 year old migrant and non-migrant women in neighboring Austria. Method: Data from a nationwide population-based survey of 7633 women is used of whom 504 (6.6%) were migrants from European Union countries and 251 (3.3%) were migrants from non-European Union countries. Logistic regression analysis was conducted to account for socio economic and health differences between the three population groups. Results: The study shows that as compared to the non-migrant women, migrant women from European Union and non-European Union countries were at lower odds of having received a pap smear in the last 12 months (adjusted odds ratio  = 0.80, 95% confidence interval = 0.66–0.96 and adjusted odds ratio = 0.74, 95%-confidence interval = 0.57–0.97, respectively). Disparities were similar with respect to utilization in the last 36 months (adjusted odds ratio = 0.60, 95% confidence interval = 0.46–0.77 and adjusted odds ratio = 0.58, 95% confidence interval = 0.40–0.82, respectively). Conclusion: The findings are in agreement with research from the majority of other countries. They suggest barriers that migrants encounter in the health system and highlight the need for diversity-sensitive health care strategies.

The effectiveness of human papillomavirus load, reflected by cycle threshold values, for the triage of HPV-positive self-samples in cervical cancer screening

Objective The performance of Cobas4800 cycle threshold value (Ct-value, reflecting viral load) combined with human papillomavirus (HPV) 16/18 genotyping was explored as a method of risk stratification to triage patients after primary HPV screening of self-collected samples. Methods The Chinese Multi-site Screening Trial database was reviewed, with focus on self-collected samples, using the results of Cobas4800 HPV assay. Quartiles of Ct-values of each genotype were used for grouping and developing screening algorithms. Diagnostic accuracy for paired comparisons between algorithms was obtained using McNemar’s test. Results A total of 10,498 women were included. The Ct-values of HPV16 and other high-risk HPV were inversely correlated with the severity of cervical lesions ( p  < 0.001). Risks for cervical intraepithelial neoplasia (CIN2+/CIN3+) were significantly stratified by Ct-values from channels detecting HPV16 and other high-risk HPV types. “HPV with HPV16/18 and reflex Ct <33.7” (algorithm G) achieved a favorable sensitivity to “HPV with atypical squamous cells of undetermined significance or worse (≥ASCUS)” (81.9% vs. 70.1% for CIN2+, p  < 0.001), a comparable sensitivity to “HPV with HPV16/18 reflex cytology ≥ASCUS” (81.9% vs. 81.3% for CIN2+, p  > 0.05), and resulted in a slightly lower specificity than the latter two algorithms (92.6% vs. 97.4% and 95.4% respectively for CIN2+, p  < 0.05). However, algorithm G achieved a comparable sensitivity to HPV testing alone for CIN3+, and reduced the colposcopy referral rate from 13.7% for HPV testing alone to 8.4%. Conclusions HPV viral loads reflected by Ct-values are associated with the severity of cervical lesions. Ct-values with an appropriate cut-off of 33.7, combined with HPV16/18 genotyping, represent a promising triage of HPV-positive women particularly for self-collected samples.

Evaluation of human papillomavirus self-collection offered by community health workers at home visits among under-screened women in Brazil

Objective To explore the acceptability of high-risk human papillomavirus self-testing, involving community health workers, for never/under-screened Brazilian women. Cervical cancer is the most common cause of cancer-related death among adult women in a large number of low-income and lower-middle-income countries, where it remains a major public health problem. High-risk human papillomavirus persistence is required for the development of cervical neoplasia. Methods The target population was all women aged 30+ from the list of families available in healthcare centre data, who had never been screened or were not screened in the previous 3 years (under-screened women), and who were living in the 17 cities included in this study. Results Of the 377 women included, 16.9% ( n = 64) had never had a pap smear. Of all samples included in the study, 97.1% ( n = 366) were considered adequate for evaluation, as 2.9% ( n = 11) were considered invalid for all high-risk human papillomavirus types. Analysing these 366 samples, 9.6% ( n = 35) of the women were infected by at least one high-risk human papillomavirus type and 90.4% ( n = 331) had no infection with any high-risk type of the virus. Conclusions Vaginal self-sampling is an adequate strategy to improve the effectiveness of the cervical cancer program by increasing screening in a high-risk group.

The ties that bind: Cancer history, communication, and screening intention associations among diverse families

Objective Breast and cervical cancers are screen-detectable; yet, challenges exist with ensuring uptake of mammography and Pap smear. Family, a central factor in developing knowledge to carry out health promotion behaviors, may be an asset to improving intention to screen among non-adherent women from underrepresented minority groups. We explored familial cancer; communication; and breast and cervical screening intention among non-adherent Black, Latina, and Arab women in the United States who participated in a randomized controlled trial of the Kin KeeperSM Cancer Prevention Intervention study. The intervention was a culturally-targeted breast and cervical cancer literacy tool for Black, Latina, and Arab women, consisting of two family-focused education sessions on the cancers, their screening guidelines, and risk-reducing health-related behaviors. Methods For this secondary analysis, we assessed family cancer history, family communication, and screening intention for breast and cervical cancer in age-eligible, non-adherent participants. Descriptive statistics examined sample characteristics of the intervention and control groups. Odds ratios were estimated from logistic regression modeling to assess the intervention and sample characteristic effects on screening intention. Results Of the 516 participants, 123 and 98 were non-adherent to breast and cervical cancer screening, respectively. The intervention (OR = 1.95 for mammography; OR = 1.62 for Pap smear) and highly communicative (OR = 2.57 for mammography; OR = 3.68 for Pap smear) families reported greater screening intention. Family history of cancer only increased screening intention for mammography (OR = 2.25). Conclusion Family-focused approaches supporting communication may increase breast and cervical cancer screening intention among non-adherent, underrepresented minority groups.

Patterns of gynaecological check-up and their association with body mass index within the CONSTANCES cohort

Objectives To investigate the relationship between patterns of gynaecological check-up and body mass index while accounting for various determinants of health care use. Methods Sequence analysis and clustering were used to highlight patterns of gynaecological check-up, which included the regularity of breast and cervical cancer screening and visits to the gynaecologist over four years, among 6182 women aged 54–65 included in the CONSTANCES cohort between 2013 and 2015 in France. Multinomial logistic regressions were used to study the association between these patterns and women’s body mass index. Results We identified four patterns of gynaecological check-up, from (A) no or inappropriate check-up (20%) to (D) almost one visit to the gynaecologist every year, overscreening for cervical cancer and frequent use of opportunistic breast cancer screening (12%). From patterns A to D, the proportion of obese women decreased and that of women with normal body mass index increased. Obese and overweight women underwent more breast than cervical cancer screening and were less often overscreened than normal weight women. These differences were only partly explained by the lower socioeconomic situation of overweight and obese women. Beyond the financial barrier, the screening modality and the type of exam may play a role. Among women who were screened for cervical cancer, obese and overweight women were less often screened by a gynaecologist. Conclusion Further efforts should be made to enhance the take-up of screening among obese women who are deterred by the healthcare system.

HPV screening performance indicators in women who previously tested HPV-negative: The second round of Vallecamonica screening programme, Northern Italy

Objective To present performance indicators from the second round of the Vallecamonica-Sebino HPV screening programme in women who had tested negative about four years earlier (mean 45 months). Methods From 2010 to 2012, the target female population (aged 25–64) was invited to the first HPV screening round. In 2013–2017, women were rescreened for the second round. HPV-negative women at the first round were initially rescreened after three years. The interval was gradually increased to five years. HPV-positive women underwent cytology triage: positives were referred to colposcopy and negatives to repeat testing after one year. If HPV was persistently positive, women were referred to colposcopy, if negative, to normal interval rescreening. Results In the second round, of 13,824 previously HPV-negative women, 598 were HPV-positive (4.3%), of whom 297 were positive at cytology triage. Of those referred to one-year HPV test, 291 complied (98.0%), 133 (50.2%) of whom were persistently positive. Total referral was 3.1% compared with 6.6% in the first round (age-adjusted relative referral 0.59, 95% CI: 0.53–0.65). There were 24 cervical intraepithelial neoplasia 2+ (three cervical intraepithelial neoplasia 3+). Detection was 0.17%, compared with 0.9% in the first round. Age-adjusted relative detections were 0.25 (95% CI: 0.16–0.39) and 0.18 (95% CI: 0.05–0.61) for cervical intraepithelial neoplasia 2+ and cervical intraepithelial neoplasia 3+, respectively. Positive predictive value was 5.7%, compared with 14.6% in the first round. Conclusions At second round, referral was half that at first round, while cervical intraepithelial neoplasia 2+ detection decreased nine-fold. Consequently, positive predictive value decreased dramatically. Rescreening four years after an HPV-negative test makes the process inefficient due to the low prevalence of lesions.

Awareness of and attitudes towards cervical cancer prevention among migrant Eastern European women in England

Objectives It has been hypothesized that, in England, the rise in incidence of cervical cancer and the fall in screening coverage might be attributable in part to the effect of migration of Eastern European born women. We explored the attitudes and behaviours of these women towards cervical cancer prevention strategies. Methods A mixed methods study using quantitative surveys and in-depth semi-structured qualitative interviews was conducted between April 2015 and December 2016. Results In total, 331 surveys and 46 interviews were completed. Native English women had greater knowledge that a smear test is a screening test for pre-cancerous cervical cells (90% vs. 71% p≤0.01), whereas migrant Eastern European women believed that it was conducted as part of a full gynaecological examination (46% vs. 21% p≤0.01) and that the screen interval was annual (18% vs. 4% p≤0.01). Distrust of the English healthcare system resulted in some Eastern European women returning to their country of birth for screening. Poor awareness of cervical cancer prior to migration and lack of information at registration with a general practitioner in England were associated with failure to participate in screening. Conclusions The views and attitudes expressed by the migrant Eastern European women in this study suggest that they are not fully participating in cervical screening in England. Targeted education at the point of contact with healthcare services in England is needed to increase cervical screening participation among these women.

Cervical cancer screening and prevention in Kazakhstan and Central Asia

Objective To examine the state of cervical screening and prevention in Central Asian states, specifically Kazakhstan. Results In the five Central Asian countries that were formerly part of the Soviet Union (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), cervical cancer incidence and mortality rates are far higher than those in most Western and high-income nations, and are increasing. Cervical cancer screening is available in all five countries, but is mainly opportunistic. Only Kazakhstan has a structured cytological screening program, from which screening coverage analysis is possible. Conclusion Despite significant decreases in cervical cancer incidence and mortality in developed countries, the problem is still of great concern in these Central Asian countries and is attributed to poorly organized screening and the absence of vaccination programs.

Attitudes towards HPV self-sampling among women in Chengdu, China: A cross-sectional survey

Objective Cervical cancer screening participation in China remains insufficient, possibly because of embarrassment or discomfort. We assessed knowledge of HPV and its link to cervical cancer, and whether HPV self-sampling might be an acceptable alternative to clinician-based screening, among Sichuan women. Methods A sample of healthy women undergoing routine physical examinations in 2017 at the West China Hospital, Sichuan University, completed a questionnaire. Results From 3000 questionnaires distributed, 1810 were completed and analyzed. Only 29.94% of respondents ( n = 542) had heard of HPV, among whom 65.75% knew that it caused cervical cancer. Among the 766 (42.32%) who considered that HPV self-sampling for cervical cancer screening was an acceptable option, over 90% thought it would be convenient, private, not embarrassing, and not painful. However, 1044 women (57.68%) did not consider self-sampling acceptable, mainly because the result might not be accurate (85.63%), specimens may have gone bad (83.05%), and they may not perform the test correctly (79.98%). Respondents who believed HPV self-sampling was acceptable were more likely than other respondents to be young, and to have completed at least secondary education. Of the 1810 respondents, 1312 (72.49%) reported that they would be willing to be vaccinated against HPV. Conclusion Most women in Chengdu lack basic knowledge about HPV. Over 40% of women believed HPV self-sampling for cervical cancer screening was an acceptable option. To increase screening coverage, public health efforts to educate the public about HPV and HPV self-sampling for cervical cancer screening should be strengthened and expanded.

“A Pap smear saved my life”: Personal experiences of cervical abnormalities shape attitudes to cervical screening renewal

Objective In 2017, the Australian National Cervical Screening Program changed from two-yearly Pap smears between ages 18 and 69, to five-yearly human papillomavirus screening between ages 25 and 74 (the “Renewal”). This study investigated attitudes towards the changes, among individuals previously affected by cervical abnormalities/cervical cancer, personally or through a friend/relative. Methods We conducted a thematic analysis of comments expressing personal history or a family/friend history of cervical abnormalities/cervical cancer as a reason for opposing changes to the cervical screening program. The comments were taken from a 20% random sample of 19,633 comments posted on the “Change.org” petition “Stop May 1st Changes to Pap Smears – Save Women's Lives” in February–March 2017. Results There were 831 (20.8%) commenters who reported that they were concerned about a change in screening due to: feelings of increased personal vulnerability to cervical cancer due to their own personal history of cervical abnormalities; comparison of extended screening intervals and later age of first screening to their own experiences; and a perception of increased personal risk due to family history. Conclusion Women previously affected by cervical abnormalities or cervical cancer, personally or through a friend/relative, expressed concern about changes to cervical screening due to perceived increased risk and feeling vulnerable due to personal history.

Reactions of women underscreened for cervical cancer who received unsolicited human papillomavirus self-sampling kits

Objectives To evaluate experiences and reactions after receiving a mailed, unsolicited human papillomavirus self-sampling kit and identify psychosocial correlates of using kits. Methods Survey participants were underscreened women aged 30–64 who were mailed human papillomavirus kits as part of a pragmatic trial at Kaiser Permanente Washington, a United States integrated health care system. Six months after the mailing, we invited kit returners and non-returners to complete a web survey that measured psychosocial factors (e.g. cervical cancer/human papillomavirus knowledge, attitudes toward screening), experiences, and reactions to kits. We compared responses between kit returners and non-returners. Results Comparing 116 kit returners (272 invited) and 119 non-returners (1083 invited), we found no clinically significant differences in psychosocial factors. Overall, survey respondents showed knowledge gaps in human papillomavirus natural history (82% did not know human papillomavirus infection can clear on its own) and interpreting human papillomavirus test results (37% did not know a human papillomavirus-negative result indicates low cancer risk). Kit returners found kits convenient and easy to use (>90%). The most common reason for non-return was low confidence in ability to correctly use a kit, although many non-returners (49%) indicated that they would consider future use. Women reported low trust in human papillomavirus testing to identify women at high risk for cervical cancer (52% in returners, 42% in non-returners). Conclusions Screening programs could improve uptake and acceptability of human papillomavirus self-sampling through outreach materials that emphasize the high efficacy of human papillomavirus testing for cervical cancer screening and educate patients about how to interpret results.

Cervical screening in Western Kazakhstan: Liquid-based cytology ‘Cell Scan’ versus azur-eosin staining

Objective To assess the effectiveness of the current cervical cancer screening tools in Western Kazakhstan. Methods Smears taken through (i) conventional cytology using azur-eosin staining and (ii) liquid-based cytology (LBC) ‘Cell Scan’ in the general female population and in women first diagnosed with cervical cancer were collected throughout the region. ROC-analysis with curve construction and weighted Cohen's κ calculation were applied. A total of 494 cytological pairs were collected, including 94 sets with histology findings. Results The conventional (azur-eosin staining) technique contained 0.2% non-informative material and LBC ‘Cell Scan’ had 5.9%. Area under the curve was 0.95 for the conventional technique and 0.92 for ‘Cell Scan’ ( p > 0.05). The conventional smears showed κ 0.62, sensitivity 90.4% at specificity 90.0% for CIN2+, while LBC ‘Cell Scan’ smears showed κ 0.47, sensitivity 83.3% at specificity 92.5%. Conclusions In this analysis it was not possible to prove that the LBC ‘Cell Scan’ technique was superior to its predecessor, azur-eosin staining. These findings highlight the need to modify the current screening programme according to updated international scientific evidence on effective screening design, such as the use of HPV DNA testing with Pap smear triage in women aged 30 or older. Further research, and a Health Technology Assessment, are necessary if we wish to establish a national standardized screening programme using the available technology appropriately.

Changes in the incidence of cervical tumours by disease stage in a cytology-based screening programme

Objectives To report changes in incidence of cervical tumours by disease stage, following the introduction of an organized cytology-based screening programme. Methods An intention-to-screen study of a cytology-based screening programme targeting 1,219,000 women aged 25–64 in northern Italy was carried out. Based on the previously reported trend in total incidence of cervical cancer, the study period 1995–2014 was divided into 1995–1996 (pre-screening, or reference, years), 1997–1998 (screening implementation phase), 1999–2006 (transition phase, when incidence decreased), and 2007–2014 (steady-state phase, when incidence stabilized again). Tumour stage was categorized as preinvasive (cervical intraepithelial neoplasia grade 3 (CIN3) and adenocarcinoma in situ), early (pT1a), advanced (pT1b or greater, ypT), and unknown (pT1 not otherwise specified, pTx, missing information). Average annual incidence rates observed in each phase were compared with the expected (reference) rates, using the incidence rate ratio, calculated with a Poisson regression model. Results In the steady-state phase, incidence rate ratios were: CIN3, 1.55 (95% confidence interval, 1.41–1.70); early-stage squamous carcinoma, 0.49 (0.36–0.67); advanced-stage squamous carcinoma, 0.44 (0.33–0.57); unknown-stage squamous carcinoma, 0.69 (0.48–0.99); adenocarcinoma in situ, 1.44 (0.72–2.88); early-stage adenocarcinoma, 2.65 (0.82–8.53); advanced-stage adenocarcinoma, 1.03 (0.56–1.91); and unknown-stage adenocarcinoma, 0.46 (0.23–0.92). Conclusions After stabilization, changes in incidence by tumour stage included a 55% increase for CIN3 and a 50–55% decrease both for early- and advanced-stage squamous carcinoma, but no significant changes for glandular tumours. These data will serve to quantify the incremental impact of the implementation of human papillomavirus-based screening, introduced in 2015.

Uptake of cancer screening among adults with disabilities in Flanders (Belgium)

Objective To explore the association between disability and participation in breast, cervical, and colorectal cancer screening in Flanders (Belgium). Methods Data from the Centre for Cancer Detection were linked to data of the Flemish Agency for disabled persons by the Crossroads Bank for Social Security, using National Social Security Numbers. Results The study population consisted of 92,334 invited individuals registered as disabled in 2013–2015. For breast cancer screening (including both opportunistic screening and participation in the screening program), 51.7% of disabled women had undergone mammography in the last two years, compared with the Flemish uptake of 61.8%. In cervical screening, 45% of the women with a disability had undergone a PAP smear in the last three years (overall Flemish uptake was 60.7%). For colorectal cancer screening, 40.7% of individuals with a disability had undergone a fecal immunochemical test in the last two years (overall Flemish uptake was 51.5%). Participation in breast and colorectal cancer screening among persons with a disability was 10% points less than the Flemish average during the same period. In the cervical cancer screening program, the difference between the participation of disabled women and the Flemish average was 10% points. Persons with any type of disability had a lower uptake of cancer screening than the Flemish average, except for individuals with a hearing impairment. Conclusions Participation disparities in the Flemish cancer screening programs between persons with and without disabilities require specific efforts to increase cancer screening among people with a disability.

Human papillomavirus self-sampling for long-term non-attenders in cervical cancer screening: A randomised feasibility study in Estonia

Objective Organised cervical cancer screening was started in Estonia in 2006, but participation is still low. Human papillomavirus (HPV) self-sampling has proved to increase screening uptake. This study addressed the feasibility of HPV self-sampling and the acceptance of this method among long-term screening non-attenders. Methods A randomised intervention study was conducted in Estonia in 2020. Women born in 1958–1983 without a Pap smear in 2013–2019 were identified in the Estonian Health Insurance Fund database. From them, 12,000 women were randomly allocated to three equal-sized study groups. The opt-out group received a questionnaire and a Qvintip® sampling device by regular mail. Two opt-in groups received a questionnaire and an e-mail invitation to order a self-sampler online; one received Qvintip and the other Evalyn® Brush. Participantś background characteristics were obtained from the Population Register. The effect of covariates on participation rate was estimated with multivariate Poisson regression. Acceptance of self-sampling was analysed according to agreement with statements in the questionnaire. Results The overall participation rate was 16% with significant differences between opt-out (26%) and opt-in (11%) groups. Compared to the opt-out Qvintip group, adjusted relative risks for the Qvintip and Evalyn Brush opt-in groups were 0.41 (95% confidence interval (CI) 0.37–0.45) and 0.44 (95% CI 0.40–0.49), respectively. Participation was associated with living place, citizenship, and education. Self-sampling was well accepted: 98% agreed that it was easy to use, 88% preferred it as a screening method in future. Conclusions The results show the feasibility and good acceptance of HPV self-sampling among long-term screening non-attenders in Estonia.

Impact of COVID-19-related care disruptions on cervical cancer screening in the United States

Objectives To quantify the secondary impacts of the COVID-19 pandemic disruptions to cervical cancer screening in the United States, stratified by step in the screening process and primary test modality, on cervical cancer burden. Methods We conducted a comparative model-based analysis using three independent NCI Cancer Intervention and Surveillance Modeling Network cervical models to quantify the impact of eight alternative COVID-19-related screening disruption scenarios compared to a scenario of no disruptions. Scenarios varied by the duration of the disruption (6 or 24 months), steps in the screening process being disrupted (primary screening, surveillance, colposcopy, excisional treatment), and primary screening modality (cytology alone or cytology plus human papillomavirus “cotesting”). Results The models consistently showed that COVID-19-related disruptions yield small net increases in cervical cancer cases by 2027, which are greater for women previously screened with cytology compared with cotesting. When disruptions affected all four steps in the screening process under cytology-based screening, there were an additional 5–7 and 38–45 cases per one million screened for 6- and 24-month disruptions, respectively. In contrast, under cotesting, there were additional 4–5 and 35–45 cases per one million screened for 6- and 24-month disruptions, respectively. The majority (58–79%) of the projected increases in cases under cotesting were due to disruptions to surveillance, colposcopies, or excisional treatment, rather than to primary screening. Conclusions Women in need of surveillance, colposcopies, or excisional treatment, or whose last primary screen did not involve human papillomavirus testing, may comprise priority groups for reintroductions.

Comparison of cytology and human papillomavirus-based primary testing in cervical screening programs in the Nordic countries

Objective To compare primary test positivity in cytology and human papillomavirus-based screening between different Nordic cervical cancer screening programs using harmonized register data. Methods This study utilized individual-level data available in national databases in Finland, Iceland, Norway, and Sweden. Cervical test data from each country were converted to standard format and aggregated by calculating the number of test episodes for every test result for each calendar year and one-year age group and test method. Test positivity was estimated as the proportion of positive test results of all primary test episodes with a valid test result for “any positive” and “clearly positive” results. Results The age-adjusted rate ratio for any positive test results in primary human papillomavirus-based screening compared to cytology was 1.66 (95% CI 1.64–1.68). The age-adjusted rate ratio for clearly positive test results was 1.02 (95% CI 1.00–1.05). A decreasing rate ratio by age was seen in both any positive and clearly positive test results. Test positivity increased over time in Iceland, Norway, and Sweden but slightly decreased in Finland. Conclusions The probability of any positive test result was higher in human papillomavirus testing than in primary cytology, even though the cross-sectional detection of a clearly positive test result was the same. Human papillomavirus testing can still lead to an improved longitudinal sensitivity through a larger number of follow-up tests and the opportunity to identify women with a persistent human papillomavirus infection. Further research on histologically verified precancerous lesions is needed in primary as well as repeat testing.

Temporal and area-level variation in prevalence of high-grade histologically confirmed cervical abnormalities among Indigenous and non-Indigenous women, Queensland, Australia, 2008–2017

Objective Despite Australia’s National Cervical Screening Program, Indigenous women have a disproportionately high burden of cervical cancer. We describe temporal and area-level patterns in prevalence of histologically conformed high-grade cervical abnormalities (hHGA) among cytologically screened women by Indigenous status. Methods This was a population-based study of 2,132,925 women, aged 20–69, who underwent cervical screening between 2008 and 2017, in Queensland, Australia. Of these, 47,136 were identified as Indigenous from linked hospital records. Overall patterns in hHGA prevalence by Indigenous status were quantified using prevalence rate ratios (PrRR) from negative binomial models. Bayesian spatial models were used to obtain smoothed prevalence estimates of hHGA across 528 small areas compared to the state average. Results are presented as maps and graphs showing the associated uncertainty of the estimates. Results Overall, screened Indigenous women had significantly higher hHGA prevalence than non-Indigenous women. However, the magnitude of the difference reduced over time ( p  < 0.001). Adjusted for age and area-level variables, Indigenous women had 36% higher hHGA prevalence (PrRR 1.36, 95% confidence interval [1.21–1.52]) than non-Indigenous women between 2013 and 2017. The overall effect of age decreased over time ( p  = 0.021). Although there was evidence of moderate spatial variation in 10-year prevalence estimates for both groups of women, the high levels of uncertainty for many estimates, particularly for Indigenous women, limited our ability to draw definitive conclusions about the spatial patterns. Conclusions While the temporal reduction in Indigenous: non-Indigenous differential in hHGA prevalence is encouraging, further research into the key drivers of the continuing higher risk among Indigenous women is warranted.

Implementation of a centralized HPV-based cervical cancer screening programme in Tuscany: First round results and comparison with the foregoing Pap-based screening programme

Objective To evaluate performance of the first round of HPV-based screening in Tuscany region and compare it with the prior round of Pap-based screening Setting Tuscany region of Italy, where HPV-based cervical cancer screening started in 2013, with a strong level of centralization screening tests at the Regional Laboratory for Cancer Prevention (ISPRO). Methods The transition from Pap- to HPV-based screening was initiated for older women and at 3 out of 12 Tuscany Local Health Units (LHUs). Data from the Florence and Grosseto LHUs (about 300,000 women) were analysed and performance screening indicators estimated. Results HPV-based indicators recorded good performance, with increased compliance vs. the Pap-based programme. We registered a substantial decrease in waiting times from sampling to test reporting, probably related to the centralization strategy. Since the screening protocol was the same and conducted at a single laboratory, we could hypothesize that the difference in HPV positivity (6.8% in Florence vs. 8.4% in Grosseto) was due to a real difference in HPV prevalence among women of the two LHUs. The transition to HPV-based screening led to a significant increase both in colposcopy referral rate (4.3% vs. 1.2%) and CIN2+ detection rate (8.3‰ vs. 3.4‰). Conclusions HPV-based is more effective in detecting high-grade precancerous and cancerous lesions than Pap-based screening and is characterized by an “anticipatory effect” in the detection of CIN2+ lesions. The transition from Pap-based to HPV-based screening programme should include increased resources dedicated to colposcopy services. Centralization in a laboratory with long experience in this field promotes efficiency of the screening process.

Aptima HPV E6/E7 mRNA and cytology cross-sectional performance as primary screening tests for detection of high-grade cervical lesions in HIV positive and negative women in South Africa

Objective To assess the performance of APTIMA ® HPV E6/E7 mRNA assay (AHPV) with HPV 16 and 18/45 genotyping (AHPV-GT) and cytology in detecting cervical cancer and precancer in HIV positive and negative women in South Africa. Methods A multicentre cross-sectional study was performed in women aged 25–64 (n = 992) with cytology and AHPV with AHPV-GT reflex testing. All screen-positive and a random subset of screen-negative women were referred for colposcopy and biopsy. Results On cytology, low-grade squamous intraepithelial lesion (LSIL) or higher was found in 9.7% of HIV negative and 35.8% of HIV positive women. HPV mRNA positivity was 19.5% (4.4% HPV 16, 2.8% HPV 18/45, and 6.9% other high-risk HPV) in HIV negative women, compared to 45.8% (9.4% HPV 16, 9.7% HPV 18/45, and 27.6% other high-risk HPV) in HIV positive women . The prevalence of histological abnormalities in HIV negative vs HIV positive women was 24.3 vs 46.0% for cervical intraepithelial neoplasia (CIN) 2+, 10.2 vs 24.1% for CIN3+, and 1.4 vs 2.4% for invasive squamous cell carcinoma. AHPV sensitivity for detection of CIN3 + performed the best: 69.0% (95% confidence interval (CI) 56.8–81.1) in HIV negative vs 81.4% (95% CI 73.7–89.0) in HIV positive women, followed by ASCUS + (atypical squamous cells of undetermined significance) cytology: 58.6% (95% CI 45.7–71.6) vs 76.5% (95% CI 68.1–84.8). The best positive predictive value for CIN2 + was for AHPV-GT16, followed by AHPV-GT16,18/45 and cytology LSIL+: HIV-negative women 84.0% (95% CI 68.9–99.1); 76.9% (95% CI 63.3–90.6); 75.0% (95 CI% 61.2–88.9) and HIV-positive women 92.5% (95% CI 84.1–100); 86.8% (95% CI 79.1–94.6); 84.0% (95% CI 77.6–90.3). Conclusion Significantly more HPV infection and cytological/histological abnormalities and advanced disease were seen in HIV positive women. The lower than expected clinical sensitivities of all screening tests are comparable to HPV DNA sensitivities reported in similar populations. AHPV with AHPV-GT performed better than cytology as a screening and triage test.

Identifying barriers and facilitators to participation in cancer screening among Irish Travellers, a minority ethnic group in Ireland, using a codesigned approach

Introduction This study sought to determine participation by eligible Irish Travellers, a minority ethnic group, in the cancer screening programmes in Ireland (bowel, breast and cervical screening) and to determine barriers/facilitators to screening. Methodology This study was co-designed with the National Cancer Control Programme (NCCP) and Pavee Point Traveller and Roma Centre, Ireland. A survey questionnaire, adapted from the NCCP's 2022 National Survey on Cancer Awareness, was disseminated to Travellers via Traveller Community Health Workers (TCHWs). Results A total of 574 survey questionnaires were distributed across 12 different Primary Health Care Traveller Projects in the Republic of Ireland and 483 (84%) were returned completed; 148 (30.6%) were from men and 306 (63.1%) from women (6.3%, missing data). High proportions had ever attended breast (72.6%) and cervical (65.4%) screening. Bowel screening uptake was low in both men (12.5%) and women (19.2%). Low proportions recalled receiving an invitation to programmes. The faecal immunochemical test test used in the BowelScreen programme prompted embarrassment as a barrier in eligible men (62.5%); embarrassment was lower in women for bowel (38.5%), breast (32.9%) and cervical (30.4%) screening. Fear was the second highest barrier. The main facilitators of screening attendance were talking to TCHW and an invitation respectively, particularly in women eligible for bowel (50%; 53.8%), breast (49.3%; 50.7%) and cervical screening (47.6%; 48.2%), but lower in men (25%; 37.5%); 25% cited the family doctor as facilitator. Conclusion Travellers face barriers accessing mainstream health services; easy access to screening must be ensured . The TCHW is a key facilitator. There is a need for universal ethnic identifiers to facilitate routine monitoring of participation and outcomes for Travellers in screening.

Ripple effect of temporary self-sampling HPV test on screening uptake in the next round: A secondary analysis of the ACCESS randomized controlled trial

The self-sampling human papillomavirus (HPV) test improves participation in cervical cancer screening. However, the ripple effect of this test on participation in the next screening round has not yet been examined. This study, a secondary analysis of the Accelerating Cervical Cancer Elimination by Self-Sampling test (ACCESS) trial, aims to clarify this effect. Women who had not participated in the cervical cancer screening program of Ichihara City for 3 years or more were included. The participants were randomly assigned to intervention ( n  = 7337) and control groups ( n  = 7770). In the initial round, the intervention group could perform a self-sampling HPV test or undergo cytology as the primary screening method, while the control group could undergo cytology only. In the next round, both groups could undergo cytology. In intention-to-screen analysis, screening uptake in the next round was 10.0% (95% confidence interval [CI]: 9.3%, 10.7%) in the intervention group and 10.2% (95% CI: 9.5%, 10.8%) in the control group, with no significant difference between groups ( p  = 0.717). In conclusion, offering a one-time self-sampling HPV test had no effect on screening uptake in the next round, suggesting that the test needs to be offered on an ongoing basis to continuously improve screening uptake.

Is GP practice bowel, breast and cervical cancer screening coverage correlated with GP practice list inflation?

Objective GP list inflation occurs when the number of patients registered at a GP practice exceeds the number of residents. It may be associated with out-of-date patient contact data, affecting invitations for cancer screening. We examined whether bowel, breast and cervical screening coverage was associated with list inflation after adjusting for deprivation and ethnicity. Methods We used ecological data, with GP practice the unit of analysis. Outcomes were NHS Fingertips 2019–2020 screening programme performance data. List inflation/deflation was calculated as the difference between GP-registered patients in July 2021 and Office for National Statistics population estimates in their Lower Super Output Areas (LSOA). Percentage White population was calculated using census (2021) data. Index of multiple deprivation (IMD) score was available from NHS Fingertips. Linear regression models were used to examine correlations between outcomes and list inflation before and after adjustment for deprivation and ethnicity. Results The study included 6085 GP practices covering the whole of England. Median list inflation was 8.6% (interquartile range (IQR) 4.7%–16.9%). List inflation was a significant independent predictor of screening coverage. For each 10 percentage points increase in list inflation, coverage declined as follows: −1.96% (95% CI: −2.19, −1.73), −2.20% (95% CI: −2.39, −2.02), −0.99% (95% CI: −1.15, −0.84) and −1.59% (95% CI: −1.75, −1.43) for breast, cervical (aged 25–49), cervical (aged 50–64) and bowel cancer screening, respectively. Conclusions It is important to control for variations in list inflation as well as population demographics when comparing screening programme coverage. Uptake improvement initiatives should include strategies for overcoming issues with out-of-date registration data.

Concurrent cancer screening participation and associated factors among Canadian women: Insights from a cross-sectional study

Objectives Colorectal, breast, and cervical cancers are leading causes of morbidity and mortality among Canadian women. While organized screening programs aim to reduce this burden, participation rates remain suboptimal, particularly for colorectal cancer screening. This study examined factors associated with colorectal cancer screening uptake among women participating in breast and cervical cancer screening ('screen-aware” women), investigated patterns of concurrent participation across all three programs, and identified associated factors. Methods Cross-sectional data from the 2017 Canadian Community Health Survey were analyzed for women aged 50–69 eligible for breast cancer (mammography), cervical cancer (Pap smear), and colorectal cancer (fecal and/or endoscopy tests) screening ( n  = 10,426). Multivariable logistic regression evaluated factors associated with colorectal cancer screening among “screen-aware” women. Multinomial logistic regression assessed factors related to full (all three), partial (any two), single, or non-participation across screening programs, using “no screening” as the reference. Results Although the majority of women (87%) participated in at least one screening program, only 27% reported full participation. Colorectal cancer screening (53.7%) lagged behind breast and cervical cancer screening (∼64%). Among “screen-aware” women, older age (adjusted odds ratio 1.50, 95% confidence interval 1.31–1.71), higher income, self-rated health as “great” (adjusted odds ratio 1.31, 95% confidence interval 1.05–1.63), and having a regular healthcare provider (adjusted odds ratio 3.29, 95% confidence interval 2.45–4.40) were associated with higher colorectal cancer screening participation. Having multiple chronic conditions reduced colorectal cancer screening likelihood (adjusted odds ratio 0.72, 95% confidence interval 0.55–0.94). Higher income, self-rated health, having a regular healthcare provider, and physical activity increased the odds of full screening participation, while smoking and Asian identity reduced the odds. Conclusions Colorectal cancer screening uptake remains low among Canadian women, even those participating in other cancer screenings. Socioeconomic, health-related, and systemic factors influence concurrent screening participation. Tailored interventions addressing identified barriers and promoting equitable access to screening are crucial for improving cancer prevention efforts.

Factors affecting young women's participation in organized cervical cancer screening and non-organized testing – A population-based survey study

Objectives Organized cervical cancer screening reduces cervical cancer incidence and mortality and is widely implemented across Europe. However, non-organized cervical cancer testing remains common. Frequent testing may lead to overdiagnosis and unnecessary treatment, especially among young women. This study aims to identify factors influencing young women's participation in organized cervical cancer screening and non-organized cervical cancer testing. Methods We surveyed 1411 women aged 15–35 living in Finland, assessing their knowledge and attitudes toward cervical cancer testing. Survey responses were linked to sociodemographic registry data and cervical cancer testing records. Descriptive statistics of survey responses and logistic regression were used to identify factors influencing participation in both organized screening and non-organized testing. Results Human papillomavirus vaccination status, medical contraception use, and gynecologist visit frequency were key predictors of non-organized testing. Human papillomavirus-vaccinated women were 50% less likely to undergo non-organized testing compared to those unvaccinated. Medical contraception users were 5.3 times more likely compared to non-users, and frequent gynecologist visitors were 1.5 times more likely to undergo non-organized testing compared to infrequent visitors. For organized screening, women with tertiary education were 4.1 times more likely to participate than those with primary education. Women appreciated the flexibility in screening times and locations. Human papillomavirus awareness was high with 91.3% of respondents having heard of the virus. Conclusions To address non-organized testing among young women, comprehensive education about human papillomavirus and cervical cancer screening is essential, both for screened women and healthcare professionals. Aligning screening practices with women's preferences may improve adherence to organized screening, ultimately benefiting public health outcomes.

HPV self-sampling in organized cervical cancer screening program: A randomized pilot study in Estonia in 2021

Background Cervical cancer incidence in Estonia ranks among the highest in Europe, but screening attendance has remained low. This randomized study aimed to evaluate the impact of opt-in and opt-out human papillomavirus (HPV) self-sampling options on participation in organized screening. Methods A random sample of 25,591 women were drawn from the cervical cancer screening target population who were due to receive a reminder in autumn 2021 and thereafter randomly allocated to two equally sized intervention arms (opt-out and opt-in) receiving a choice between HPV self-sampling or clinician sampling. In the opt-out arm, a self-sampler was sent to home address by regular mail; the opt-in arm received an e-mail containing a link to order a self-sampler online. The remaining 30,102 women in the control group received a standard reminder for conventional screening. Participation by intervention arm, age and region of residence was calculated; a questionnaire was used to assess self-sampling user experience. Results A significant difference in participation was seen between opt-out (41.7%) (19.8% chose self-sampling and 21.9% clinician sampling), opt-in (34.1%) (7.9% self-sampling, 26.2% clinician sampling) and control group (29.0%, clinician sampling only). All age groups and regions in the intervention arms showed higher participation compared to the control group, but the size of the effect varied. Among self-sampling users, 99% agreed that the device was easy to use and only 3.5% preferred future testing at the clinic. Conclusion Providing women with a choice between self-sampling and clinician sampling significantly increased participation in cervical cancer screening. Opt-in and opt-out options had a different effect across age groups, suggesting the need to adapt strategies.

Public cervical cancer screening recommendations from US cancer centers: Assessing adherence to national guidelines

Though widespread adoption of cervical cancer screening (CCS) in the US has been associated with a reduction in cervical cancer incidence and mortality, screening also carries with it potential risks. Newer national guidelines recommend decreased screening frequency to optimize the benefit/risk balance and to prevent over-screening. Here, we examined the alignment of US cancer center websites’ public recommendations on CCS with national guidelines. We reviewed the websites of 1024 cancer centers accredited by the US Commission on Cancer during January–August 2022. We recorded the recommended frequency and type of CCS and any screening risks mentioned, comparing against national US Preventive Service Task Force (USPSTF) and American Cancer Society (ACS) guidelines. Of 1024 US cancer centers, 60% (610) provided CCS recommendations. Most centers are in alignment with the screening starting age (96%, 544/565) and stopping age (94%, 440/470) recommended by national guidelines. Of 508 centers specifying the frequency of standalone cervical cytology, 83% (419) recommended a screening interval of three years; however, 14% (73) recommended cervical cytology more frequently than the three-year interval recommended by the ACS/USPSTF. Screening risks were mentioned by 20% (124/610) of centers. Our findings highlight the importance of education on screening benefits and risks for physicians and patients to enable shared decision making based on evidence-based guidelines.

Awareness and knowledge about HPV and primary HPV screening among women in Great Britain: An online population-based survey

Objectives Human papillomavirus (HPV) primary testing for cervical screening is being implemented around the world. We explored HPV awareness, and knowledge about primary screening in Great Britain (England, Scotland and Wales), where it has been in place for several years, ahead of extended screening intervals being implemented in England. Setting/Methods Women aged 18–70 ( n = 1995) were recruited by YouGov from their online panel in August 2022. The weighted sample ( n = 1930) was population-representative by age, region, education and social grade. We measured HPV awareness, knowledge (excluding those unaware of HPV) using eight true/false items, and understanding of the role of HPV testing in cervical screening. Results Overall, 77.6% (1499/1930) of women were aware of HPV. When asked to identify the statement describing how cervical screening works, only 12.2% (236/1930) correctly selected the statement reflecting HPV primary screening (13.5% (194/1436) in screening-eligible women). Excluding those unaware of HPV, most participants had heard about the virus in the context of cervical screening (981/1596; 61.5%) or HPV vaccination (1079/1596; 67.6%). Mean knowledge score was 3.7 out of 8 (SD = 2.2) in this group. Most knew that an HPV-positive result does not mean a woman will definitely develop cervical cancer (1091/1499; 72.8%) but far fewer were aware of the long timeline for HPV to develop into cervical cancer (280/1499; 18.7%). Conclusions Only three-quarters of women in Britain are aware of HPV, and knowledge of primary screening is very low, even among screening-age women. This points to continued need for awareness-raising campaigns to ensure informed choice about screening and mitigate public concern when screening intervals are extended.

Primary human papillomavirus testing by clinician- versus self-collection: Awareness and acceptance among cervical cancer screening-eligible women

Objectives Primary human papillomavirus (HPV) testing by clinician-collection is endorsed by U.S. guideline organizations for cervical cancer screening, but uptake remains low and insights into patients’ understanding are limited. This study aims to primarily address patient awareness of primary HPV screening by clinician-collection and acceptance of primary HPV screening by clinician- and self-collection, and secondarily assess factors associated with awareness and acceptance. Setting Primary care practices affiliated with an academic medical center. Methods A cross-sectional survey study of screening-eligible women aged 30–65 years was conducted to assess awareness and acceptability of primary HPV screening. We analyzed bivariate associations of respondent characteristics with awareness of primary HPV screening by clinician-collection, willingness to have clinician- or self-collected primary HPV testing, and reasons for self-collection preference. Results Respondents (n = 351; response rate = 23.4%) reported cervical cancer screening adherence of 82.8% but awareness of clinician-collected primary HPV as an option was low (18.9%) and only associated with HPV testing with recent screening ( p = 0.003). After reviewing a description of primary HPV screening, willingness for clinician-collected (81.8%) or home self-collected (76.1%) HPV testing was high, if recommended by a provider. Acceptability of clinician-collected HPV testing was associated with higher income ( p = 0.009) and for self-collection was associated with higher income ( p = 0.002) and higher education ( p = 0.02). Higher education was associated with reporting self-collection as easier than clinic-collection ( p = 0.02). Women expected self-collection to be more convenient (94%), less embarrassing (85%), easier (85%), and less painful (81%) than clinician-collection. Conclusions Educational interventions are needed to address low awareness about the current clinician-collected primary HPV screening option and to prepare for anticipated federal licensure of self-collection kits. Informing women about self-collection allows them to recognize benefits which could address screening barriers.

Estimating stage-specific sensitivity for cancer screening tests

Objectives When evaluating potential new cancer screening modalities, estimating sensitivity, especially for early-stage cases, is critical. There are methods to approximate stage-specific sensitivity in asymptomatic populations, both in the prospective (active screening) and retrospective (stored specimens) scenarios. We explored their validity via a simulation study. Methods We fit natural history models to lung and ovarian cancer screening data that permitted estimation of stage-specific (early/late) true sensitivity, defined as the probability subjects screened in the given stage had positive tests. We then ran simulations, using the fitted models, of the prospective and retrospective scenarios. Prospective sensitivity by stage was estimated as screen-detected divided by screen-plus interval-detected cancers, where stage is defined as stage at detection. Retrospective sensitivity by stage was estimated based on cancers detected within specified windows before clinical diagnosis with stage defined as stage at clinical diagnosis. Results Stage-specific true sensitivities estimated by the lung cancer natural history model were 47% (early) and 63% (late). Simulation results for the prospective setting gave estimated sensitivities of 81% (early) versus 62% (late). In the retrospective scenario, early/late sensitivity estimates were 35%/57% (1-year window) and 27%/49% (2-year window). In the prospective scenario, most subjects with negative early-stage screens presented as other than early-stage interval cases. Results were similar for ovarian cancer, with estimated prospective sensitivity much greater than true sensitivity for early stage, 84% versus 25%. Conclusions Existing methods for approximating stage-specific sensitivity in both prospective and retrospective scenarios are unsatisfactory; improvements are needed before they can be considered to be reliable.

Interval cancer audit and disclosure in cervical screening programmes: An international survey

Background Legal cases involving the National Cervical Screening Programme in Ireland following non-disclosure of an interval cervical cancer audit prompted this first international comparative survey of interval cervical cancer audit. Methods A survey of 22 international population-based cervical screening programmes was conducted, to determine if they undertook audit of invasive cervical cancers. Those countries/regions that perform reviews were asked (i) how the audit was undertaken, including how the reviews were performed and how they controlled for retrospective bias, (ii) how women are informed of the audit process and how their consent is obtained, and (iii) how audit results were disclosed to patients. Results Seventeen countries/regions invited completed the survey (77%); 65% (11/17) have an audit process for interval cervical cancers. Five perform individual patient reviews; three perform programme-wide review, with calculation of interval cancer detection rates; one routinely performs programme-wide review with calculation of interval cancer detection rates and offers individual reviews, and one routinely performs local hospital-level reviews. In the remaining country/region, hospital laboratories audit cancers, with a national audit process for all cervical cancers. Varying methodologies for retrospective cytology review were employed; four include control samples, with a ratio varying from 1:1 to 1:2. Three conduct a blinded review. Most countries/regions do not discuss interval cancer audit with participants and 3/11 (27.3%) inform women when a cervical cancer audit takes place. Disclosure is limited and variable. Conclusion The responses suggest that there is no consistent approach to audit of interval cervical cancers or to disclosure of audit results.

Participation in the national cervical screening programme among women from New South Wales, Australia, by place of birth and time since immigration: A data linkage analysis using the 45 and up study

Objective Equitable elimination of cervical cancer in Australia within the next decade will require high National Cervical Screening Program (NCSP) participation by all subgroups of women. The aim of this study was to examine the participation of immigrants compared to Australian-born women. Methods Participation in the NCSP (≥1cytology test) over a 3-year (2010–2012) and 5-year (2008–2012) period, by place of birth and time since immigration was examined using individually linked data of 67,350 New South Wales (NSW) women aged ≥45 enrolled in the 45 and Up Study. Results Three-year cervical screening participation was 77.0% overall. Compared to Australian-born women (77.8%), 3-year participation was lower for women born in New Zealand (adjusted odds ratio 0.77, 95% confidence interval 0.69–0.87), Oceania (0.67, 0.51–0.89), Middle East/North Africa (0.76, 0.60–0.97), South-East Asia (0.72, 0.60–0.87), Chinese Asia (0.82, 0.69–0.97), Japan/South Korea (0.68, 0.50–0.94), and Southern/Central Asia (0.54, 0.43–0.67), but higher for women from Malta (2.85, 1.77–4.58) and South America (1.33, 1.01–1.75). Non-English-speaking-at-home women were less likely to be screened than English-speaking-at-home women (0.85, 0.78–0.93). Participation increased with years lived in Australia but remained lower in immigrant groups compared to Australian-born women, even after ≥20 years living in Australia. Similar results were observed for 5-year participation. Conclusions Women born in New Zealand, Oceania, and parts of Asia and the Middle East had lower NCSP participation, which persisted for ≥20 years post-immigration. The NCSP transition to primary HPV screening, and the introduction of the universal self-collection option in 2022, will offer new opportunities for increasing screening participation for these groups.

Maximising the acceptability of extended time intervals between screens in the NHS Cervical Screening Programme: An online experimental study

Objective The NHS Cervical Screening Programme plans to increase the screening interval from 3 to 5 years for women aged 25–49 who test negative for human papillomavirus (HPV). This exploratory cross-sectional online survey tested the impact of different levels of information about the proposed change on acceptability of a longer interval. Methods Women aged 18–45 (n = 585) were individually randomised to one of three information exposure groups differing in the level of information provided about the screening interval change: (1) basic information; (2) basic information with additional detail about timeline of HPV infection; (3) as (2) but with the addition of a diagram. Acceptability of the change ( favourable and unfavourable attitudes ) was assessed post-exposure alongside HPV timeline beliefs. We used ANOVA and regression analyses to test for between-group differences. Results Women in Group 3 had higher scores on the favourable attitudes sub-scale compared with Group 1. Women in Groups 2 and 3 had more accurate timeline beliefs than those in Group 1. There were no between-group differences in unfavourable attitudes . After adjusting for demographic factors, a higher favourable attitudes score was independently predicted by being in Group 3 compared to Group 1, more accurate HPV timeline beliefs, and previous irregular or non-attendance at screening. Conclusions Overall, acceptability of an increased screening interval was moderate, but providing women with information about the safety and rationale for this change may improve acceptability. In particular, communicating the long timeline from HPV exposure to cervical cancer may reassure women about the safety of the proposed changes.

Technological advances: Have they improved standards? Review of outcomes from the Welsh cervical screening programme

Objectives Introduction of new technologies into cervical screening programmes has allowed more efficient programmes with less resources. We present an overview of screening technologies introduced into the Cervical Screening Wales programme and their evolution over time. Methods Data from the programme’s statistical report were used to evaluate its performance over a 17-year period between 2001/02 and 2017/18. Results The introduction of liquid-based cytology has had a substantial impact on reducing inadequate sample rates and on increasing the positive predictive value of cytology. Inadequate rates have increased following the implementation of human papilloma virus testing as a triage test for cytology. Further knock-on effects on standard reporting ranges are expected following the introduction of human papilloma virus testing as the primary screening test. New performance standards have been introduced to better reflect the performance of the programme at a time when disease prevalence is expected to fall as women vaccinated against human papilloma virus reach screening age. Conclusions Improvements to this cervical cancer screening programme as illustrated through performance indicator ranges suggest a major role played by technology.

Determinants of (non-)attendance at the Dutch cancer screening programmes: A systematic review

Objective The Netherlands host three population-based cancer screening programmes: for cervical, breast, and colorectal cancer. For screening programmes to be effective, high participation rates are essential, but participation in the Netherlands’ programmes is starting to fall below the minimal effective rate. We aimed to produce a systematic overview of the current known determinants of (non-)attendance at the Dutch cancer screening programmes. Methods A literature search was conducted in the electronic databases Academic Search Premier, Cochrane Library, Embase, EMCare, PubMed, PsycINFO, Web of Science, and also in grey literature, including all articles published before February 2018. The I-Change model was used to categorize the identified determinants of cancer screening attendance. Results In total, 19/1232 identified studies and 6 grey literature reports were included. Fifteen studies reported on predisposing factors. Characteristics such as social economic status, country of birth, and residency were most often reported, and correlate with cancer screening attendance. Thirteen studies addressed information factors. Factors on awareness, motivation, ability, and barriers were less often studied. Conclusion Current studies tend to describe the general characteristics of (non-)attendance and (non-)attenders, but rarely provide in depth information on other factors of (non-)participation. The I-Change model proved to be a useful tool in mapping current knowledge on cancer screening attendance and revealed knowledge gaps regarding determinants of (non-)participation in the screening programmes. More research is needed to fully understand determinants of participation, in order to influence and optimize attendance rates over the long term.

Concurrent participation in screening for cervical, breast, and bowel cancer in England

Objectives To determine how many women participate in all three recommended cancer screening programmes (breast, cervical, and bowel). During their early 60s, English women receive an invitation from all the three programmes. Methods For 3060 women aged 60–65 included in an England-wide breast screening case–control study, we investigated the number of screening programmes they participated in during the last invitation round. Additionally, using the Fingertips database curated by Public Health England, we explored area-level correlations between participation in the three cancer screening programmes and various population characteristics for all 7014 English general practices with complete data. Results Of the 3060 women, 1086 (35%) participated in all three programmes, 1142 (37%) in two, 526 (17%) in one, and 306 (10%) in none. Participation in all three did not appear to be a random event ( p < 0.001). General practices from areas with less deprivation, with more patients who are carers or have chronic illnesses themselves, and with more patients satisfied with the provided service were significantly more likely to attain high coverage rates in all programmes. Conclusions Only a minority of English women is concurrently protected through all recommended cancer screening programmes. Future studies should consider why most women participate in some but not all recommended screening.

Offering an app to book cervical screening appointments: A service evaluation

Objective To assess the feasibility of offering women who are overdue for cervical screening the use of a smartphone app to book their appointment. Methods Women who were at least six months overdue for cervical screening in three general practice surgeries in a deprived East London borough were identified from practice records. Staff sent batches of text messages informing women that they were overdue for screening, and inviting them to download an app to book their appointment. Results Across the three practices, 2632 eligible women were identified. Valid mobile phone numbers were available for 1465 women. One woman had opted out of receiving text messages, so messages were sent to 1464 women. Of these, 158 (11%) booked a screening appointment within five months. The majority of these women booked without using the app (72%; 113/158); just over a quarter booked via the app (28%; 45/158). Conclusions Just over 10% of cervical screening non-attenders booked an appointment in response to a text message with a link to a downloadable app; however, only one in four of these women booked using the app. This suggests that the text message reminder was likely to have been the key ‘active ingredient’ for most women, rather than the app itself. Future research could explore the optimal message for a text reminder in this context and evaluate the inclusion of a link to existing online booking systems.

Impact of changes to cervical screening guidelines on age and interval at which women are tested: Population-based study

Background English cervical screening programme guidelines changed between 2009 and 2012. We explore the impact on the age and intervals at which women receive a cytology test. Methods Eligible women were controls from a population-based case–control study in England. Tests taken between 1980 and 2017 were extracted from the call/recall database. Using the Kaplan–Meier estimator by birth cohort and age at (or time since) last test, we explore proportions tested since or prior to a given age, years since previous test, and interval following a negative test. Results Screening histories from 46,037 women were included. Proportion tested by age 26 has increased from 55% among birth cohorts 1978–1979 to 67% among those born 1990–1991, despite more recent cohorts only having received one invitation (instead of two) prior to age 26. The proportion of women tested at aged 28 with a test three years earlier increased by 20% (from 36% in 1997–2006 to 56% in 2012–2017) whereas the proportion tested at ages 23–27 without a prior test increased from 34% to 80%. The age at last test prior to exiting the programme has decreased: among those born 1928–1931 86% had a test aged 60–65, but only 71% of those born 1947–1951. Conclusion Clear programme guidance alongside quality assurance has improved the cervical screening programme by standardising the age and intervals at which women are screened.

Populations at high risk of cervical cancer in Guangxi Province: Findings from two screening projects in a minority area of South China

Objective To analyse the positive rates of low-grade (LSIL) and high-grade (HSIL) squamous intraepithelial lesions, and cervical cancer (CC), and identify groups at high risk for CC in Guangxi. Setting CC screening options in Guangxi, which is the only minority autonomous area in South China, include the National Cervical Cancer Screening Project (NCCSP) and physical examination (PE). Methods This study was based on PE and NCCSP sample data obtained from 2012 to 2019. We calculated the positive rates of LSIL, HSIL, and CC; analysed the adjusted odds ratio (aOR) and 95% confidence intervals (CI) of the variables in multivariate logistic regression; and subsequently identified groups at high risk for CC. Results The positive rates of LSIL, HSIL, and CC for the total of 873,880 samples were 1.89%, 0.60%, and 0.03%, respectively. Females over 64 years of age (vs. 50–64; aOR = 2.05; 95% CI, 1.71–2.46; P < 0.001) and those from urban (vs. rural; aOR = 1.66; 95% CI, 1.57–1.76; P < 0.001), minority (vs. non-minority; aOR = 1.24; 95% CI, 1.13–1.35; P < 0.001), and coastal (vs. inland; aOR = 1.15; 95% CI, 1.06–1.25; P = 0.001) areas were associated with a high risk of HSIL. Females over 64 (vs. 50–64; aOR = 4.37; 95% CI, 2.88–6.63; P < 0.001) and those from urban (vs. rural; aOR = 3.05; 95% CI, 2.36–3.95; P < 0.001) areas were significantly associated with a high risk of CC. Conclusion Females from urban areas in Guangxi are at high risk for CC. Public health strategies should focus on high-risk populations.

Cervical screening attendance and cervical cancer risk among women who have sex with women

Objectives To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk. Methods We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK. Results Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08–0.13), WSWM 0.73 (0.58–0.91), and women who have never had sex 0.02 (0.01–0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake ( p  = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29–0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24). Conclusions These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.

“It's cancer screening after all”. Barriers to cervical and colorectal cancer screening and attitudes to promotion of self-sampling kits upon attendance for breast cancer screening

Objectives To explore barriers to cervical and colorectal cancer screening and attitudes to promotion of self-sampling kits upon attendance for breast cancer screening. Methods Interview study with women who had not responded to one or more invitations to cervical or colorectal cancer screening. A semi-structured interview guide was used and interviews were audio recorded and transcribed verbatim. Concepts from Temporal Motivation Theory were used to structure and analyse the data. Results Twenty-two women were interviewed. Screening was highly valued but the women perceived screening for cervical cancer and colorectal cancer as more troublesome to participate in, compared with participation in breast cancer screening. The lack of a pre-booked appointment or a suggested deadline attenuated the perceived value of cervical and colorectal cancer screening and this further increased procrastination. Promotion of self-sampling kits for cervical and colorectal cancer screening upon attendance for breast cancer screening was considered a feasible way to increase salience of both types of screening. Conclusion A high number of micro steps and absence of a deadline in cervical and colorectal cancer screening diverted attention away from screening participation in cervical and colorectal cancer screening. The main facilitator could be reduction of micro actions, proposing a suggested deadline, and promotion of self-sampling kits when attending breast cancer screening to increase salience and a renewed attention to all three screening programmes.

Interval cancer audit and disclosure in breast screening programmes: An international survey

Objective and Setting Accurate monitoring of interval cancers is important both for quality improvement and education and is a key parameter of breast screening quality assurance. Issues in relation to communication regarding interval cervical cancer in the Irish cervical screening programme were found, prompting interval cancer process review in all cancer screening programmes. An international survey to examine international consensus on interval breast cancer audit processes was conducted to inform Irish processes. Methods A survey of 24 international population-based breast screening programmes was done to determine which undertook audit of interval breast cancer; if yes, they were asked (1) how they undertake audit, (2) if they obtain individual consent for audit and inform women of audit results, and (3) if disclosure of audit results occurs. Results Response was 71% (17/24). Of these, 71% (12/17) have a programmatic audit process to calculate the interval cancer rate (ICR). Of these, ten also carry out radiological reviews, three using a blinded review. Two inform patients that audit is taking place; two provide choice to be in the audit; nine state that routine screening consent covers audit. For two of the five that have an open disclosure policy for medical incidents, this policy applies to screening interval cancers. One other country/region has an open disclosure policy for category 3 interval cancers only. Five have legal protection for interval cancers arising in the screened population. Conclusion While consistency in providing aggregate programmatic audits exists, there is no consistent approach to individual interval cancer reviews or results disclosure.

Self-sampling for cervical screening offered at the point of invitation: A cross-sectional study of preferences in England

Objectives This study assessed preferences for human papillomavirus (HPV) self-sampling if offered as an alternative to clinician-based screening at the point of invitation for cervical screening. Setting and Methods An online questionnaire was completed by screening-eligible women living in England (n = 3672). Logistic regressions explored associations between demographic characteristics and screening preferences, stratified by previous screening attendance. Reasons for preferences were also assessed. Results Half of participants (51.4%) intended to choose self-sampling, 36.5% preferred clinician screening, 10.5% were unsure, and <2% preferred no screening. More irregular and never attenders chose self-sampling, compared with regular attenders (71.1% and 70.1% vs. 41.0% respectively). Among regular attenders, self-sampling was preferred more frequently by the highest occupational grade, older and lesbian, gay and bisexual women, and those with experience of blood self-tests. In the irregular attender group, older women and those with experience of blood self-tests were more likely to choose self-sampling. In ‘never attenders’, self-sampling was less popular in ethnic minority groups. Conclusions If offered a choice of screening, around half of women in England may choose self-sampling, but a substantial proportion would still opt for clinician screening. Screening providers will need to manage a high take-up of self-sampling if many regular attenders switch to self-sampling.

COVID-19 disruption to cervical cancer screening in England

Introduction In England, routine invitations for cervical screening were reduced between April 2020 and June 2020 due to the COVID-19 pandemic. We quantify the impact of COVID-19 disruptions on attendance and excess diagnoses of cervical cancer (CC). Methods Using Public Health England CC screening data on laboratory samples received in 2018 as a baseline we quantify the reduction in screening attendances due to the COVID-19 pandemic between April 2020 and March 2021 for women aged 25–64. We model the impact on excess CC diagnoses assuming once invitations resume 87.5% of women attend within 12 months and 12.5% delay screening for 3 or 5 years (depending on age). Results The number of samples received at laboratories was 91% lower than expected during April, 85% during May and 43% during June 2020 compared to the same period in 2018. Although on average laboratories received 12.6% more samples between August 2020 and April 2021 than over the same months in 2018, by April 2021 there was a short fall of 200,949 samples (6.4% fewer than in 2018). An excess of 41 CC (4.0 per 100,000 women with a maximum screening delay of 12 months) are predicted to occur among the estimated 1,024,794 women attending this screening round with a delay. An excess of 60 CC (41.0 per 100,000 women) are predicted to occur among the estimated 146,391 women who do not attend this screening round. Conclusion Prompt restoration of cervical screening services limited the impact on excess CC diagnoses. However, in 2020 a 6.4% shortfall of screening samples was observed. Every effort should be made to reassure these women that services are open and safe to attend.