Human papillomavirus detection in cervical scrapes from women attended in the Family Health Program

Objectives

to survey the prevalence of human papillomavirus, associated risk factors and genotype distribution in women who were referred to cervical cancer screening when attended in a Family Health Program.

Method

we conducted a cross-sectional survey, investigating 351 women. Polymerase chain reaction for DNA amplification and restriction fragment length polymorphism analysis were used to detect and typify the papillomavirus.

Results

virus infection was detected in 8.8% of the samples. Among the 21 different genotypes identified in this study, 14 were high risk for cervical cancer, and the type 16 was the most prevalent type. The infection was associated with women who had non-stable sexual partners. Low risk types were associated with younger women, while the high risk group was linked to altered cytology.

Conclusion

in this sample attended a Family Health Program, we found a low rate of papillomavirus infection. Virus frequency was associated to sexual behavior. However, the broad range of genotypes detected deserves attention regarding the vaccine coverage, which includes only HPV prevalent types.     

An Analysis of Mass Screening Strategies Using a Mathematical Model: Comparison of Breast Cancer Screening in Japan and the United States

Background

Although the United States Preventive Services Task Force (USPSTF) downgraded their recommendation for breast cancer screening for women aged 40–49 years in 2009, Japanese women in their 40s have been encouraged to attend breast cancer screenings since 2004. The aim of this study is to examine whether these different mass-screening strategies are justifiable by the different situations of these countries and to provide evidence for suitable judgment.

Methods

Performance of screening strategies (annual/biennial intervals; initiating/terminating ages) was evaluated using a mathematical model based on the natural history of breast cancer and the transition between its stages. Benefits (reduced number of deaths and extended average life expectancy) and harm (false-positives) associated with these strategies were calculated.

Results

Additional average life expectancy by including women in their 40s as participants were 13 days (26%) and 25 days (22%) in Japan and the United States, respectively, under the biennial screening condition; however, the respective increases in numbers of false-positive cases were 65% and 53% in Japan and the United States. Moreover, the number of screenings needed to detect one diagnosis or to avert one death was smaller when participants were limited to women of age 50 or over than when women in their 40s were included. The validity of including women in their 40s in Japan could not be determined without specifying the weight of harms compared to benefits.

Conclusions

Whether screening of women in their 40s in Japan is justifiable must be carefully determined based the quantitative balance of benefits and harms.Key words: breast cancer, mass screening, mathematical model, benefit, harm     

A Community-based Cervical Cancer Screening Program among Women of Delhi using Camp Approach

Background:

Cervical cancer is the commonest malignancy among women in developing countries. Cytological screening (Pap smear) have been claimed to reduce incidence and mortality of carcinoma cervix significantly for which sensitization of women is required through community-based approach.

Objectives:

To find out number of cervical cancer cases among patients reporting to a general health care camp through screening program and study the prevalence of perceived morbidity and its confirmation.

Settings:

Cross-sectional study among women attending cancer awareness camps.

Materials and Methods:

A total of 435 women attending cancer awareness camps were screened for carcinoma cervix. The findings of history and clinical examination were recorded. Pap smears of all the symptomatic patients were collected and cytological diagnosis was confirmed by a pathologist.

Results and Conclusions:

The perceived gynecological morbidity was observed to be 59.8%. The smear of the women who were suspected of carcinoma on clinical examination was confirmed to be the cases of carcinoma-in-situ (7.8%) and high-grade neoplasia (2.9%) on laboratory investigations. The findings of the study highlight the utility and need of cancer cervix screening among the women at regular intervals through camp approach in the community.     

An Examination of Pay‐for‐Performance in General Practice in Australia

Objective

This study examines the impact of Australia''s pay-for-performance (P4P) program for general practitioners (GPs). The voluntary program pays GPs A$40 and A$100 in addition to fee-for-service payment for providing patients recommended diabetes and asthma treatment over a year, and A$35 for screening women for cervical cancer who have not been screened in 4 years.

Design

Three approaches were used to triangulate the program''s impact: (1) analysis of trends in national claims for incentivized services pre- and postprogram implementation; (2) fixed effects panel regression models examining the impact of GPs'' P4P program participation on provision of incentivized services; and (3) in-depth interviews to explore GPs'' perceptions of their own response to the program.

Results

There was a short-term increase in diabetes testing and cervical cancer screens after program implementation. The increase, however, was for all GPs. Neither signing onto the program nor claiming incentive payments was associated with increased diabetes testing or cervical cancer screening. GPs reported that the incentive did not influence their behavior, largely due to the modest payment and the complexity of tracking patients and claiming payment.

Implications

Monitoring and evaluating P4P programs is essential, as programs may not spark the envisioned impact on quality improvement.     

Effect of Payment Incentives on Cancer Screening in Ontario Primary Care

PURPOSE

There is limited evidence for the effectiveness of pay for performance despite its widespread use. We assessed whether the introduction of a pay-for-performance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program.

METHODS

We performed a longitudinal analysis using administrative data to determine cancer screening rates and incentive costs in each fiscal year from 1999/2000 to 2009/2010. We used a segmented linear regression analysis to assess whether there was a step change or change in screening rate trends after incentives were introduced in 2006/2007. We included all Ontarians eligible for cervical, breast, and colorectal cancer screening.

RESULTS

We found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. Colon cancer screening was increasing at a rate of 3.0% (95% CI, 2.3% to 3.7%) per year before the incentives were introduced and 4.7% (95% CI, 3.7% to 5.7%) per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Between 2006/2007 and 2009/2010, $28.3 million, $31.3 million, and $50.0 million were spent on financial incentives for cervical, breast, and colorectal cancer screening, respectively.

CONCLUSIONS

The pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening.     

Effect of providing risk information on undergoing cervical cancer screening: a randomized controlled trial

Background

In Japan, the cervical cancer screening rate is extremely low. Towards improving the cervical cancer screening rate, encouraging eligible people to make an informed choice, which is a decision-making process that relies on beliefs informed by adequate information about the possible benefits and risks of screening, has attracted increased attention in the public health domain. However, there is concern that providing information on possible risks of screening might prevent deter from participating.

Methods

In total, 1,912 women aged 20–39 years who had not participated in screening in the fiscal year were selected from a Japanese urban community setting. Participants were randomly divided into 3 groups. Group A received a printed reminder with information about the possible benefits of screening, group B received a printed reminder with information about possible benefits and risks, and group C received a printed reminder with simple information only (control group).

Results

Out of 1,912 participants, 169 (8.8%) participated in cervical cancer screening. In the intervention groups, 137 (10.9%) participated in cervical cancer screening, compared to only 32 (4.9%) of the control group (p < 0.001). In addition, logistic regression analysis revealed that there was no significant difference in screening rate between group A and group B (p = 0.372).

Conclusions

Providing information on the possible risks of screening may not prevent people from taking part in cervical cancer screening among a Japanese non-adherent population.     

Personality and Gastric Cancer Screening Attendance: ?A Cross-Sectional Analysis from the Miyagi Cohort Study

Objective

To determine the associations between personality subscales and attendance at gastric cancer screenings in Japan.

Methods

A total of 21,911 residents in rural Japan who completed a short form of the Eysenck Personality Questionnaire-Revised (EPQ-R) and a questionnaire on various health habits including the number of gastric cancer screenings attended were included in the primary analysis. We defined gastric cancer screening compliance as attendance at gastric cancer screening every year for the previous 5 years; all other patterns of attendance were defined as non-compliance. We defined gastric cancer screening visiting as attendance at 1 or more screenings during the previous 5 years; lack of attendance was defined as non-visiting. We used logistic regression to estimate the odds ratios (ORs) of gastric cancer screening compliance and visiting according to 4 score levels that corresponded to the 4 EPQ-R subscales (extraversion, neuroticism, psychoticism, and lie).

Result

Extraversion had a significant linear, positive association with both compliance and visiting (trend, P < 0.001 for both). Neuroticism had a significant linear, inverse association with compliance (trend, P = 0.047), but not with visiting (trend, P = 0.21). Psychoticism had a significant linear, inverse association with both compliance and visiting (trend, P < 0.001 for both). Lie had no association with either compliance or visiting.

Conclusion

The personality traits of extraversion, neuroticism, and psychoticism were significantly associated with gastric cancer screening attendance. A better understanding of the association between personality and attendance could lead to the establishment of effective campaigns to motivate people to attend cancer screenings.Key words: attendance, cross-sectional study, gastric cancer screening, Japanese, personality     

Statistical analyses in Swedish randomised trials on mammography screening and in other randomised trials on cancer screening: a systematic review

Objectives

We compared calculations of relative risks of cancer death in Swedish mammography trials and in other cancer screening trials.

Participants

Men and women from 30 to 74 years of age.

Setting

Randomised trials on cancer screening.

Design

For each trial, we identified the intervention period, when screening was offered to screening groups and not to control groups, and the post-intervention period, when screening (or absence of screening) was the same in screening and control groups. We then examined which cancer deaths had been used for the computation of relative risk of cancer death.

Main outcome measures

Relative risk of cancer death.

Results

In 17 non-breast screening trials, deaths due to cancers diagnosed during the intervention and post-intervention periods were used for relative risk calculations. In the five Swedish trials, relative risk calculations used deaths due to breast cancers found during intervention periods, but deaths due to breast cancer found at first screening of control groups were added to these groups. After reallocation of the added breast cancer deaths to post-intervention periods of control groups, relative risks of 0.86 (0.76; 0.97) were obtained for cancers found during intervention periods and 0.83 (0.71; 0.97) for cancers found during post-intervention periods, indicating constant reduction in the risk of breast cancer death during follow-up, irrespective of screening.

Conclusions

The use of unconventional statistical methods in Swedish trials has led to overestimation of risk reduction in breast cancer death attributable to mammography screening. The constant risk reduction observed in screening groups was probably due to the trial design that optimised awareness and medical management of women allocated to screening groups.     

Integration of comprehensive women’s health programmes into health systems: cervical cancer prevention,care and control in Rwanda

Problem

Although it is highly preventable and treatable, cervical cancer is the most common and most deadly cancer among women in Rwanda.

Approach

By mobilizing a diverse coalition of partnerships, Rwanda became the first country in Africa to develop and implement a national strategic plan for cervical cancer prevention, screening and treatment.

Local setting

Rwanda – a small, landlocked nation in East Africa with a population of 10.4 million – is well positioned to tackle a number of “high-burden” noncommunicable diseases. The country’s integrated response to infectious diseases has resulted in steep declines in premature mortality over the past decade.

Relevant changes

In 2011–2012, Rwanda vaccinated 227 246 girls with all three doses of the human papillomavirus (HPV) vaccine. Among eligible girls, three-dose coverage rates of 93.2% and 96.6% were achieved in 2011 and 2012, respectively. The country has also initiated nationwide screening and treatment programmes that are based on visual inspection of the cervix with acetic acid, testing for HPV DNA, cryotherapy, the loop electrosurgical excision procedure and various advanced treatment options.

Lessons learnt

Low-income countries should begin to address cervical cancer by integrating prevention, screening and treatment into routine women’s health services. This requires political will, cross-sectoral collaboration and planning, innovative partnerships and robust monitoring and evaluation. With external support and adequate planning, high nationwide coverage rates for HPV vaccination and screening for cervical cancer can be achieved within a few years.     

Peer Reviewed: Cholesterol Screening by Marital Status and Sex in the United States

Introduction

Marital status may be a predisposing factor related to preventive health screenings, which may in part explain the "healthy marriage" effect. This study investigates differences in the likelihood of being screened for cholesterol by marital status for men and women.

Methods

Medical Expenditure Panel Surveys from 2003 through 2005 were used to calculate the likelihood of self-reported cholesterol screening in the past year by marital status and sex. Several rounds of interviews during a 2-year period resulted in a sample of 36,594 US adults.

Results

Most married, widowed, and divorced/separated people reported cholesterol screening in the past year. The highest percentages of people being screened for cholesterol were widowed men (75%) and women (81%). By contrast, 26% of single men and 38% of single women reported cholesterol screening. In multivariate models, being unmarried was associated with lower odds of cholesterol screening among men and women. The lowest likelihood of screening was associated with widowed status for both men (odds ratio, 0.56) and women (odds ratio, 0.53).

Conclusion

Marital status is a predisposing factor for cholesterol screening. Public health interventions aimed at improving preventive screening should focus on social networks, especially family members.     

Visual Inspection with Acetic Acid (VIA) Screening Program: 7 Years Experience in Early Detection of Cervical Cancer and Pre-Cancers in Rural South India

Cervical cancer continues to be a major public health problem in India in the absence of wide spread organised cervical screening programs. Visual inspection of the cervix with acetic acid (VIA) is an effective, inexpensive screening test that can be combined with simple treatment procedures for early cervical lesions, provided by trained health workers. We report 7 years experience in early detection of cervical cancer and pre-cancers using the VIA test in a community-based program in rural Andhra Pradesh, India where there are no existing organised cervical screening programs.

Materials and Methods:

Eligible women aged between 26 and 60 were opportunistically screened by trained health wor kers using the VIA test. Women who tested positive were further evaluated and those with cervical lesions were treated either by cryotherapy in the screening clinic or referred to a higher center.

Results:

A total of 18,869 women were screened by a single round of VIA testing with a positive rate of 10.75%. Biopsy proven high-grade squamous intraepithelials (HSILs) were 90 (0.48%) and low-grade squamous intraepithelials (LSILs) were 43 (0.28%). The overall prevalence of cervical intraepithelial neoplasia (CIN) 2+ lesion rate is 1.05%. A total of 312 (1.65%) cryotherapies were done and 49 women underwent hysterectomy.

Conclusions:

VIA by trained female health workers is a safe, acceptable, and effective test that can save lives from cervical cancer even in remote areas with few resources. These results have important implications for efficient service delivery in cervical screening programs in low-resourced settings.     

Cervical cancer screening in the United States and the Netherlands: a tale of two countries

Context

This article compares cervical cancer screening intensity and cervical cancer mortality trends in the United States and the Netherlands to illustrate the potential of cross-national comparative studies. We discuss the lessons that can be learned from the comparison as well as the challenges in each country to effective and efficient screening.

Methods

We used nationally representative data sources in the United States and the Netherlands to estimate the number of Pap smears and the cervical cancer mortality rate since 1950. The following questions are addressed: How do differences in intensity of Pap smear use between the countries translate into differences in mortality trends? Can population coverage rates (the proportion of eligible women who had a Pap smear within a specified period) explain the mortality trends better than the total intensity of Pap smear use?

Findings

Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were quite similar. The five-year coverage rates for women aged thirty to sixty-four were quite comparable at 80 to 90 percent. Because screening in the Netherlands was limited to ages thirty to sixty, screening rates for women under thirty and over sixty were much higher in the United States. These differences had consequences for age-specific mortality trends. The relatively good coverage rate in the Netherlands can be traced back to a nationwide invitation system based on municipal population registries. While both countries followed a “policy cycle” involving evidence review, surveillance of screening practices and outcomes, clinical guidelines, and reimbursement policies, the components of this cycle were more systematically linked and implemented nationwide in the Netherlands than in the United States. To a large extent, this was facilitated by a public health model of screening in the Netherlands, rather than a medical services model.

Conclusions

Cross-country studies like ours are natural experiments that can produce insights not easily obtained from other types of study. The cervical cancer screening system in the Netherlands seems to have been as effective as the U.S. system but used much less screening. Adequate coverage of the female population at risk seems to be of central importance.     

Comparison of Cardiovascular Risk Screening Methods and Mortality Data among Hungarian Primary Care Population: Preliminary Results of the First Government-Financed Managed Care Program

Introduction

Besides participation in the primary prevention, screening as secondary prevention is an important requirement for primary care services. The effect of this work is influenced by the characteristics of individual primary care practices and doctors’ screening habits, as well as by the regulation of screening processes and available financial resources. Between 1999 and 2009, a managed care program was introduced and carried out in Hungary, financed by the government. This financial support and motivation gave the opportunity to increase the number of screenings.

Method

4,462 patients of 40 primary care practices were screened on the basis of SCORE risk assessment. The results of the screening were compared on the basis of two groups of patients, namely: those who had been pre-screened (pre-screening method) for known risk factors in their medical history (smoking, BMI, age, family cardiovascular history), and those randomly screened. The authors also compared the mortality data of participating primary care practices with the regional and national data.

Results

The average score was significantly higher in the pre-screened group of patients, regardless of whether the risk factors were considered one by one or in combination. Mortality was significantly lower in the participating primary practices than had been expected on the basis of the national mortality data.

Conclusion

This government-financed program was a big step forward to establish a proper screening method within Hungarian primary care. Performing cardiovascular screening of a selected target group is presumably more appropriate than screening within a randomly selected population. Both methods resulted in a visible improvement in regional mortality data, though it is very likely that with pre-screening a more cost-effective selection for screening may be obtained.     

Peer Reviewed: Factors Associated With Cervical Cancer Screening in Puerto Rico

Introduction

Racial/ethnic disparities in cervical cancer screening exist in the United States; rates are lowest among women who live in Puerto Rico. We identified factors associated with cervical cancer screening among women aged 18 years or older living in Puerto Rico.

Methods

We included women who participated in the Puerto Rico Behavioral Risk Factor Surveillance System in 2006 who had not had a hysterectomy (n = 2,206). We calculated the weighted population prevalence estimates of Papanicolaou (Pap) test screening in the past 3 years and used logistic regression models to assess factors associated with screening.

Results

Most participants (71.9% [95% confidence interval (CI)Most participants (71.9% [95% confidence interval (CI) = 69.4%-74.4%]) reported having had a Pap test in the preceding 3 years. Factors associated with screening in multivariate analysis included routine checkup in the past year and leisure-time physical activity. Compared with women with a household income less than $15,000, those with higher incomes were more likely to have had a Pap test. Similarly, divorced or separated women were more likely to have been screened (odds ratio [OR] = 1.13; 95% CI = 1.12-1.15) than those who were married/living together. We did not find associations between screening behavior and education, health care coverage, body mass index, or smoking status.

Conclusion

The prevalence of cervical cancer screening in Puerto Rico is below the 90% recommendation established by Healthy People 2010. Our findings regarding factors associated with Pap screening behavior identified population subgroups who are underscreened and who may benefit from targeted interventions and screening programs.     

Innovative public–private partnership: a diagonal approach to combating women’s cancers in Africa

Problem

In low- and middle-income countries, breast and cervical cancer have a poor prognosis, partly owing to barriers to treatment. To redress this situation, health systems must be strengthened.

Approach

Pink Ribbon Red Ribbon (PRRR) is an innovative partnership designed to leverage public and private investments in global health and to build on the successful United States President’s Emergency Plan for AIDS Relief (PEPFAR) platform to combat cancers of the breast and cervix in sub-Saharan Africa and Latin America. By supporting a comprehensive set of country-owned and country-driven interventions, PRRR seeks to reduce deaths from cervical cancer among women screened and treated through the programme and to reduce deaths from breast cancer by promoting early detection.

Local setting

In its initial phase, PRRR is supporting the governments of Botswana, Zambia and other countries in expanding cervical cancer prevention, screening and treatment coverage – especially to high-risk women with human immunodeficiency virus infection – and in strengthening breast cancer education and control services.

Relevant changes

PRRR has introduced a diagonal strategy based on the life course and continuum of care approaches to cancer control. Its work has resulted in the delivery of the human papillomavirus vaccine to young girls in several settings and in the strengthening of prevention, screening and treatment delivery systems from the community to the tertiary level.

Lessons learnt

This paper outlines the approach PRRR has taken as a country-aligned public–private partnership and the preliminary lessons learnt, including the need for flexible implementation, effective country coordination mechanism and regular communication with all stakeholders.     

Peer Reviewed: Nonadherence to Breast and Cervical Cancer Screening: What Are the Linkages to Chronic Disease Risk?

Background

Several preventive practices that reduce chronic disease risk have been associated with breast and cervical cancer screening, including maintenance of normal weight and avoidance of cigarette smoking. A history of certain chronic illnesses such as diabetes and cardiovascular disease has also been related to cancer screening. Nevertheless, studies that have attempted to identify women who are less likely to have had a recent breast or cervical cancer screening test have infrequently examined the associations of breast and cervical cancer screening with multiple health factors that influence chronic disease risk.

Methods

To clarify relationships between cancer screening and health behaviors and other factors that influence chronic disease risk, we examined the self-reported breast and cervical cancer screening practices of women in the United States by using data from the 1999 Behavioral Risk Factor Surveillance System. The women were described according to their recent use of mammography and the Papanicolaou test, physician visits within the past year, health insurance coverage, and preventive practices that reduce chronic disease risk.

Results

Overall, 74.5% (95% CI, 73.9%-75.1%) of the women in this sample aged 40 years or older (n = 56,528) had received a mammogram within the past 2 years. The percentage of women who had been screened for breast cancer, however, varied widely by factors associated with reducing the risk of chronic disease (e.g., cholesterol check in the past 2 years, blood pressure check in the past 2 years, normal weight, avoidance of cigarette smoking) and having access to health care (e.g., health insurance coverage, recent physician visit). Similarly, 84.4% (95% CI, 83.9%-84.9%) of all women aged 18 years or older who had not undergone a hysterectomy (n = 69,113) had received a Papanicolaou test in the past 3 years, and factors associated with reduced chronic disease risk and health care access were related to having had a recent Papanicolaou test.

Conclusion

The results of this study suggest that underscreened women who are at risk for breast and cervical cancer are likely to benefit from programs that identify and address coexisting prevention needs. The identification of coexisting prevention needs might assist in developing interventions that address multiple risks for chronic disease among women and might subsequently help improve the efficiency and effectiveness of prevention programs.     

Mean Sojourn Time of Preclinical Gastric Cancer in Korean Men: A Retrospective Observational Study

Objectives:

This retrospective cohort study aimed to estimate the mean sojourn time (MST) of preclinical gastric cancer in Korean men.

Methods:

The subjects consisted of voluntary male screenees aged 40 to 69 years who underwent subsequent screening gastroscopies after testing negative at a baseline screening performed between January 2007 and December 2011. A new case was defined if gastric cancer cells were present in the biopsy specimens obtained from gastroscopy. The follow-up period was calculated as the number of person-years between the date of baseline screening gastroscopy and positive findings at a subsequent screening. The MST was calculated using transition rates of gastric cancer to determine the best screening interval.

Results:

Of the 171 979 voluntary male screenees, 61 688 (36%) underwent subsequent screening gastroscopies between January 2007 and December 2011. A total of 91 incident cases were found during 19 598 598 person-years of follow-up. The MST of gastric cancer was 2.37 years (95% confidence intervals, 1.92 to 2.96), and those aged 40 to 49 years had a shorter MST than those 50 to 69 years did.

Conclusions:

These findings support the 2-year interval of screening recommended by the nationwide gastric cancer screening program in Korea. Further studies for the age-specific MST among women are needed.     

Rates of Change to a Positive Result in Subsequent Screening Mammography in Korean Women: A Retrospective Observational Study

Objectives:

This retrospective cohort study aimed at calculating some parameters of changes in the findings of the subsequent screening mammography (SSM) in female Korean volunteers.

Methods:

The study included screenees aged 30 to 79 years who underwent SSM voluntarily after testing negative in the baseline screenings performed between January 2007 and December 2011. A change to a positive result was defined as category 4 or 5 by using the American College of Radiology Breast Imaging Reporting and Data System. The proportion of results that had changed to positive (CP, %) was calculated by dividing the number of cases with results that were positive in the SSM by the total number of study participants. The rate of results that had changed to positive (CR, cases per 100 000 screenee-months) was calculated by dividing the number of cases with results that were positive in the SSM by the total number of months of the follow-up period.

Results:

The overall CP and CR in all age groups (n=77 908) were 2.26% and 93.94 cases per 100 000 screenee-months, respectively. The median CP interval in the subjects who had positive SSM results was 30 to 36 months, while that in the age group of 30 to 39 years was shorter.

Conclusions:

Different screening intervals should be considered among women aged between 30 and 59 years. In addition, a strategy for a screening program should be developed for the age group of 30 to 39 years, in particular.