Cervical cancer screening among Cambodian-American women.

Southeast Asian women have higher invasive cervical cancer incidence rates and lower Pap testing frequencies than most other racial/ethnic groups in the United States. However, there is little information about the cervical cancer screening behavior of Cambodian-American women. Cambodian residents of Seattle were surveyed in person during late 1997 and early 1998. The PRECEDE model was used to guide the development of items that assessed predisposing, reinforcing, and enabling factors associated with cervical cancer screening participation. The estimated overall survey response was 72%. Four hundred thirteen women completed our questionnaire. Approximately one-quarter (24%) of the respondents had never had a Pap test, and over one-half (53%) had not been screened recently. The following variables were positively associated with a history of at least one Pap smear: younger age, greater number of years since immigration, belief about Pap testing for postmenopausal women, prenatal care in the United States, and physician recommendation. Women who believed in karma were less likely to have ever been screened for cervical cancer than those who did not. Six variables independently predicted recent screening: age; beliefs about regular checkups, cervical cancer screening for sexually inactive women, and the prolongation of life; having a female doctor; and a previous physician recommendation for Pap testing. The study findings indicate that culturally specific approaches might be effective in modifying the cervical cancer screening behavior of immigrant women. Programs targeting Cambodian-Americans are likely to be more effective if they are multifaceted and simultaneously address predisposing, reinforcing, and enabling factors.     

The effectiveness of interventions to promote mammography among women with historically lower rates of screening.

This study examines mammography-enhancing intervention studies that focus on women in groups with historically lower rates of mammography use than the general population. These groups consist of women who are disproportionately older, poorer, of racial-ethnic minorities, have lower levels of formal education, and live in rural areas. We refer to them as diverse populations. The purpose of this report is to determine which types of mammography-enhancing interventions are most effective for these diverse populations. For this report, United States and international studies with concurrent controls that reported actual receipt of mammograms (usually based on self-report) as an outcome were eligible for inclusion. Intervention effects were measured by differences in intervention and control group screening rates postintervention and were weighted to reflect the certainty of each study's contribution. These effects differed significantly (Q = 218, 34 df), and the variation between studies was best explained by indicators of the use of access-enhancing approaches. Combined intervention effects were estimated for different categories of intervention types using random effects models for subgroups of studies. The strongest combination of approaches used access-enhancing and individual-directed strategies and resulted in an estimated 27% increase in mammography use (95% confidence interval, 9.9-43.9, nine studies). Additionally impressive was the access-enhancing and system-directed combination (20% increase and 95% confidence interval, 8.2-30.6, five studies). Access-enhancing strategies are an important complement to individual- and system-directed interventions for women with historically lower rates of screening.     

Cervical cancer screening rates in the United States and the potential impact of implementation of screening guidelines

The remarkable success achieved in cervical cancer prevention is largely attributable to cervical cytology screening, also known as the Papanicolaou (Pap) test. The American Cancer Society (ACS) revised screening guidelines for Pap testing in 2002. The impact of these changes on future numbers of Pap tests has not been assessed. Using National Health Interview Survey (NHIS) data to determine historical screening patterns, we extrapolate the numbers of Pap tests that would be performed through 2010, under 5 different scenarios of implementation of screening guidelines. From 1993 to 2003, there was a steady increase in the number of Pap tests, with an estimated 65.6 million Pap tests performed in 2003. Approximately two thirds of women born after 1930 reported having been screened within the previous year, and 85% within the previous 3 years. Fifteen percent of Pap tests were performed in hysterectomized women, most of whom, according to current guidelines, should not be screened. Based on population projections, if screening behavior remains unchanged, 75 million Pap tests will be performed in 2010. Full compliance with ACS guidelines would approximately halve the total number of tests to 34 million. Potentially, with more appropriate allocation of resources according to guidelines, all women could be screened and the total number of Pap tests reduced, despite projected increases in the population.     

Cervical screening participation and risk among Swedish-born and immigrant women in Sweden

Cervical cancer is one of the most common cancers among women worldwide, although cervical screening has reduced the incidence in many high-income countries. Low screening uptake among immigrant women may reflect differences in risk of cervical cancer. We investigated the degree of participation in cervical screening among immigrant and Swedish-born women and their concurrent risk of cervical cancer based on individual information on Pap smears taken both from organized and opportunistic screening. Mean degree of participation in cervical screening was estimated for women between 23 and 60 years from 1993 to 2005, stratified by birth region and age at migration. In Poisson regression models, we estimated relative risks (RRs), incidence rates and incidence rate ratios of cervical cancer for women adhering or not to the cervical screening program. We also assessed effect of adherence to screening on the risk of cervical cancer among immigrant groups compared to Swedish-born women. The degree of participation was 62% and 49% among Swedish-born and immigrant women, respectively, with large variations between immigrant groups. Participation was lowest among those immigrating at older ages. Swedish-born and immigrant women who where nonadherent to the cervical screening program had a fivefold excess risk of cervical cancer compared to adherent women. After adjustment for screening adherence, excess RRs of cervical cancer were statistically significant only for women from Norway and the Baltic States. Participation to screening is lower among immigrant than Swedish-born women, and adherence to the recommended screening intervals strongly prevents cervical cancer.     

Cervical cancer screening

Although primary prevention of human papillomavirus (HPV) infections that are causally associated with invasive cervical cancer may be within our grasp, it is unlikely that these approaches will replace existing cervical cancer screening strategies for many years. Experts agree and data support periodic cytology screening for young-adult women using one of several technologies. Recent analyses of cost-effectiveness suggest that the addition of molecular HPV DNA testing for women aged over 30 years may allow the screening interval to be lengthened to 3 years for most women. Women at high risk for HPV infection and its associated cellular atypias warrant closer monitoring and follow-up. These patients would include organ transplant recipients, women exposed to diethylstilbestrol (DES), and HIV-infected women.     

Cervical cancer screening

There is abundant evidence that cervical cancer screening with conventional cytology(CC)has reduced mortality from cervical cancer. Based on the evidence, CC has been implemented as a modality of the population-based screening for the last several decades in Japan. Several issues are currently faced during screening. For instance, very low coverage is one of the greatest unsolved problems. At the same time, a reliable system is required to monitor specimen adequacy and to calculate detection rates of not only invasive cancer, but also cervical intraepithelial neoplasia(CIN), for the quality control and evaluation of screening efficacy. Recently, two new modalities may be applicable for cervical cancer screening. One is liquid-based cytology(LBC)and the other is the HPV test. LBC and CC did not differ significantly in terms of sensitivity and specificity for detection of CIN2+or CIN3+. HPV tests are superior to CC in sensitivity but are inferior in specificity for detection of CIN2+or CIN3+. Because there is a possibility reducing mortality from and incidence of invasive cervical cancer, implementation of these modalities to Japan should be taken into consideration. Prior to this, however, it is necessary to organize a system to compare performance indicators reflecting the effectiveness of the new modalities to those of CC in a population-based screening. Also, these results must be disclosed for a steady perspective on the cervical cancer screening in Japan.     

Cervical cancer screening

Cervical cytology has proved to be one of the most successful examples of cancer screening and has resulted in significant decreases in incidence and mortality from invasive cervical cancer in regions in which comprehensive programs have been instituted. A standardized system of reporting abnormal cervical cytology, the Bethesda System has been developed and revised to reflect our current understanding of HPV-related precancers. The Pap smear has been the backbone of cervical cancer screening programs in North America over the past five decades; however, recent advances, including liquid-based cytology, HPV typing, and direct visualization techniques, are proposed to address the inherent weaknesses of cytologic screening in women who are screened. The problem of unscreened and underscreened women exists and accounts for most cases of invasive cancer. Widespread screening hopefully one day will lead to a significant decrease in the mortality of cervical cancer, the second most common female malignancy worldwide. Another means of preventing this disease involves HPV vaccines, which are in development but are not ready for use outside of a clinical trial.     

Cervical cancer screening in Ireland

Screening for cervical cancer commenced in Ireland on an opportunistic basis in the late 1960s. The Data Protection Act was recently amended to allow access to specific databases for the purpose of setting up an age sex register for breast and cervical cancer screening. A pilot cervical screening programme is planned for women aged 25-60 years living in the Mid Western Area Health Board region.     

Cervical cancer screening in Luxembourg

In 1962, a programme for early detection of cervical cancer was established at the national level. The programme is based on the collaboration of different groups of doctors and not on a system of sending out invitations to every woman. This programme was re-adapted twice according to the needs for assuring quality in a system of mainly liberal medicine. At present the programme is 'institutionalised' and is carried out according to the criteria defined in 1990. This includes a centralisation of the smear readings and handing out the material needed to take the smears. The contribution of the doctors is regulated by a system of bonuses given by the government and a reimbursement by the Health Fund. The annual cervical smear is free of charge for every woman. The participation of the women targeted by the programme (>15 years old) has increased by approximately 50% every decade from the early 1970s increasing from 10950 in 1972 to 70441 in 1999. Between 1980 and 1999, the number of women at risk taking part in the programme increased from 10.80 to 38.92%. The number of all the doctors taking smear samples increased from 68 to 105 and the number of gynaecologists increased from 19 (ratio Gyn/GP (gynaecologists/General Practitioners) of 28%) to 52 (ratio Gyn/GP of 50%). The mortality rate has decreased continuously from 6. 1/100000 in 1990 to 0.9/100000 in 1997. In conclusion, to be successful, a cervical cancer screening programme should be flexible enough to allow short-term adaptations to unexpected local situations and needs a highly motivated team of the different participants involved in the regional and national health policy.     

Cervical cancer screening in Greece

The aim of this study was to describe the state of the art in cervical cancer screening in Greece by presenting the two regionally organised screening programmes that currently operate in the country. Both programmes were initiated in 1991 and are partly funded by the European Union. The Ormylia screening programme covers the population of Halkidiki (Northern Greece), a predominantly rural area. The second programme covers the regions of Messinia and Ilia (Southern Greece). Both programmes are targeted at women aged 25-64 years of age and a Papanicolaou (Pap) smear test is recommended every 2-3 years. Electoral and municipal registries are used to identify the target population and personal invitations are sent to the eligible women in the screening programme. The Ormylia programme is based at the Centre 'Our Lady Who Loves Mankind', whereas mobile units are used by the Messinia and Ilia programme. Slide reading for the Ormylia programme is performed in the cytology laboratory of Alexandra Hospital in Athens and epidemiological support is provided by the Department of Hygiene and Epidemiology (Medical School, University of Athens). A specifically designed database is used for data recording. Over 80% of the target population in the region have already been screened. Communication of results is by means of a personal letter upon a negative result and in person upon a suspicious result. Quality assurance in both programmes is based on the European protocol. These two programmes are the sole organised cervical cancer screening activities in Greece in the absence of a national programme. They employ well-trained personnel, they use modern equipment and have strict quality assurance procedures.     

Cervical cancer screening in Denmark

Denmark is divided into 15 counties and it is up to regional politicians and the health authority in each county to organise the cervical screening programmes. The National Board of Health issued national guidelines and recommendations for the cervical cancer screening back in 1986, and these guidelines are now, in 1998, almost fully implemented. In this study, a literature review on cervical cancer screening in Denmark, review of local guidelines, personal interviews with pathologists and collection of information about the education of cytotechnologists in Denmark was carried out. In Denmark in 1997 90% of women aged 23-59 years and 46% of women aged 60-74 years were covered by organised screening. A total of 650000 smears were taken annually. This figure corresponds to screening of all Danish women aged 25-59 years on average, every second year. The national recommendation is screening every third year. Thus, as the incidence of cervical cancer in Denmark is decreasing, we could probably move towards a longer screening interval. However, before the Danish recommendations are changed, more detailed data on the actual performances of screening programmes are warranted.     

Cervical cancer screening in Italy

Until recently cervical cancer screening in Italy has been mainly spontaneous, with only a few organised programmes. This resulted in low coverage and high frequency of tests in screened women (mostly every year). The situation is, however, rapidly changing. In 1996 nationwide organised programmes, on a regional basis, were recommended. National guidelines recommend personal invitation of women aged 25-64 years for a Pap-test every third year. At the end of 1999 34% of the Italian population 25-64 years old was included in organised programmes. Most organised programmes have fail-safe systems for women referred for colposcopy, protocols for diagnostic work-up and treatment and reference centres for such phases, according to the recommendations of national and European guidelines. However the size of laboratories is frequently smaller than recommended. Most organised programmes implement quality assurance processes for cytology interpretation, that have been intensive in some centre, but there is no nationwide standardisation. In recent years data for monitoring screening activity have been collected in a standardised way by most organised programmes, in the framework of GISCi (Italian Group for Cervical Cancer Screening) allowing internal and external comparisons. In some cases strong improvements of coverage after the introduction of an organised activity have been documented. Data, however, suggest a relevant heterogeneity of criteria for cytology interpretation, requiring actions to increase consistency. The impact of these transformations on incidence of cervical cancer will be observed in the future: preliminary results suggest a reduction in older programmes.     

Cervical cancer screening in France

In France, as in other European countries the incidence and mortality rates of carcinoma of the cervix uteri indicate a clear decrease in invasive cancers. Opportunistic screening has spread and, presently, approximately 60% of the female population undergo a regular cytological test. This rate increases up to 80% in the younger age groups and decreases to 20% after the age of 60 years. In 1990, intervention procedures were defined at a consensus conference; the major recommendations were to screen all women exclusively by cervical smears, for ages 25-65 years over a 3-year period. Guidelines on the quality control of cervical smear taking and reading were published by the national agency of evaluation of health intervention (ANAES). Since 1990, four population-based, organised pilot programmes, have been implemented in Isère. Doubs, Bas-Rhin and Martinique. These programmes evaluate the participation rate (from approximately 20-80% depending upon the age and the geographical area), the rate of abnormal tests (0.2-3%), according to the laboratories, the cancer detection rate (0.04%-0.15%) and some other quality indicators. Recently (November 1998) a law was passed stipulating that the screening test will be free of charge when performed in agreement with the national recommendations. A specific organisation for cytological quality control will be implemented. An effort to better identify and to include the screening process the women in the population who are not yet participating has to be made.     

Cervical cancer screening in England

Cervical screening in England is provided free of charge by the National Health Service to all women aged 20-64 years. Computerised call and recall was introduced in 1988 and women receive an invitation every 3-5 years. Smears are taken by the local family doctor, by his/her nurse or at community clinics. Approximately 85% of English women have had a smear in the last 5 years. Quality assurance programmes have recently been established for laboratories and colposcopy clinics and lessons have been learned from previous failures of the service. The incidence has fallen from 16 per 100000 in 1986 to 9.3 per 100000 in 1997. Mortality is currently falling by 7% per year.     

Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country

Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).     

Cervical cancer screening in Germany

Cervical cancer is one of the target cancers covered by the statutory German cancer screening programme which was introduced in West Germany in 1971 and expanded to the eastern part of the country in 1991. Women covered by statutory health insurance (over 90% of the female population) are eligible to receive an annual cervical examination including a Papanicolaou (PAP) smear beginning at age 20 years. Annual uptake currently slightly exceeds 50% of the eligible population. Shortly after implementation of the national screening programme in the early 1970s the incidence of invasive cervical cancer decreased moderately and the incidence of cervical carcinoma in situ increased substantially in the state of Saarland. These observations would be expected as a result of a cervical cancer screening programme with substantial uptake. Although quality assurance guidelines for cervical cancer screening have been adopted and updated since the inception of the screening programme, only minor changes have been made in the cross-sectional programme documentation. Implementation of population-based documentation and evaluation of screening activities is currently being developed for the German cancer screening programme in pilot studies implementing the European guidelines on the quality assurance of mammography screening. After demonstration of feasibility and effectiveness, improvements in the quality management of breast cancer screening will subsequently be applied to the cervical cancer screening programme.