Cervical Cancer Screening: Recommendations for Muslim Societies

Background: The overall cervical cancer incidence rate is low in Iran; however, because of a higher risk of death for cervical cancer, a disease that kills women in middle age, a cervical cancer control program is needed. The aim of this study was to provide consensus recommendation for cervical cancer prevention in Iran and other Muslim societies with low incidences of cervical cancer. Materials and Methods: Through a practical guideline development cycle, we developed six questions that were relevant to produce the recommendation. We reviewed 190 full text records of cervical cancer in Iran (1971 to 2013) of which 13 articles were related to the data needed to answer the recommendation questions. We also reviewed World Health Organization, IARC, GLOBOCAN report, Iran Ministry of Health cancer registry report and 8 available foreign countries guidelines. Lastly, we also evaluated the Pap smear results of 825 women who participated in the Iranian HPV survey, of whom 328 were followed-up after a 5-year interval. Results: The obtained data highlighted the burden of HPV and cervical cancer situation in Iran. Experts emphasized the necessity of a cervical cancer screening program for Iranian women, and recommended an organized screening program with a cytological evaluation (Pap smear) that would start at the age of 30 years, repeated every 5 years, and end at the age of 69 years. Meanwhile, there is no need for screening among women with a hysterectomy, and screening should be postponed to post-partum among pregnant women. Conclusions: An organized cervical cancer screening is a necessity for Iran as more than 500-900 women in middle age diagnosed with an invasive cervical cancer every year cannot be ignored. This recommendation should be taken into account by the National Health System of Iran and Muslim countries with shared culture and behavior patterns. CUBA HPV test could be consideration in countries Muslim country with appropriate budget, resources and facility.     

Efficacy of a Training Course Given by Midwives Concerning Cervical Cancer Risk Factors and Prevention

Background: Cervical cancer is the second most common cancer type seen among women in most countriesand an important cause of mortality. Although it is a preventable disease, most women living in developingcountries cannot reach effective screening programs. It is essential that appropriate education about cervicalcancer is provided. Objective: This experimental field study was performed with the aim of evaluating theefficacy of training given to women about cervical cancer risk factors and primary and secondary preventionprecautions. Methods: The research focused on women between 25 and 29 years of age, literate, married andhaving social security. The study was conducted in the district of Evka 4 Health Care Center between the datesof April to August 2005. The women were given survey forms and questionnaires in order to determine theirsocio-demographic features and knowledge level about cervical cancer in the course of home visits. They weretrained and given a manual at the data collection stage. At a second visit, carried out three months later, thetrained women were again evaluated for their knowledge level about cervical cancer, risk factors and whetherthey had undergone a Pap smear test. Results: Together with the difference between pre-/post-training meaninformation scores related to women’s cervical cancer risk factors, the difference between the women’s havinga Pap smear test in the pre-/post-training period was found statistically significant. Only 16.3% of the womenstated that they had a Pap smear test in the post-training period. Conclusions: It was determined that thewomen were in need of knowledge about risk factors related to cervical cancer, prevention from and earlydiagnosis of cervical cancer, but there was no significant increase in the rate of having a Pap smear test despitethe increase in the knowledge level with the training given.     

Self-Collection Tools for Routine Cervical Cancer Screening: A Review

Sub-optimal participation is a major problem with cervical cancer screening in developing countries whichhave no organized national screening program. There are various notable factors such as ‘embarrassment’,‘discomfort’ and ‘no time’ cited by women as they are often also the bread winners for the family. Implementationof self-sampling methods may increase their participation. The aim of this article was to provide a survey ofvarious types of self-sampling tools which are commonly used in collection of cervical cells. We reviewed currentlyavailable self-sampling devices and collated the advantages and disadvantages of each in terms of its acceptanceand its accuracy in giving desired results. In general, regardless of which device is used, self-sampling for cervicalscrapings is highly acceptable to women in most of the studies cited.     

The Pap-Smear Test Experience of Women in Turkey: A Qualitative Study

Objective: The study was planned with the purpose of examining the attitude of women who have pap-smeartest for the early diagnosis of cervical cancer, factors affecting their decisions and their feelings and experiencesduring this period. Materials and Methods: A phenomenological method was used. Data were collected betweenMarch 2012 and April 2012 using standard and purposive samplings from 17 women. A detailed interview withwomen were held in their houses and recorded. The data collection tool consisted of two parts, one of which isinformation form with 17 questions identifying sociodemographic and cervical cancer risk factors of women andthe second part is made up of semi-structured interview form with 15 alternative questions taking literature andthe pap-smear test into consideration. Collected data were put into a written document. Content analysis washeld by loading the documents into NVIVO 8 Statistical Programme. Results: The study comprised themes suchas cervical risk factor, decision of taking pap-smear test, taking pap-smear test, knowledge about pap-smear test,relieving factors during pap-smear test, obstructive factors during pap-smear test, gynecological examinationand feelings of women during and after pap-smear test while waiting for the results. Conclusions: As womenperceive gynaecological examinations differently from other examinations, they have different feelings in eachprocess of the Pap smear test. Medical staff should advise women more clearly on the nature and advantages ofthe Pap-smear test.     

Knowledge about Cervical Cancer Risk Factors and Pap Smear Testing Behavior among Female Primary Health Care Workers: A Study from South Turkey

Background: Cervical cancer is one of the ten most frequent cancers in Turkey. We here examined knowledgeabout cervical cancer in relation to Papanicolaou (Pap) testing among female primary health care workers inHatay, a city is located in the south of Turkey. Materials and Methods: The study was completed on 261 womenhealthcare workers who were or had been sexually active and who accepted to participate to the study. Theparticipants gave verbal informed consent and thereafter questionnaires prepared by the investigators wereadministered by personal interview. Results: Only 30.3% (n=79) of the participants regularly had a gynecologicexamination. While 87.4% (n=228) of the participants reported that they had already heard about the Pap smeartest, only 45.2% (n=118) had undergone this test. It was determined that had undergone an average of 1.66±0.89times (1-4) within the last five years. Some 56.0% (n=117) of the participants were well informed about the Papsmear test (p<0,001) and 81.1% (n=63) of the participants who regularly had gynecological examinations (p<0,001)had this test. Conclusions: For the early diagnosis of the cervical cancer, regularly having a Pap smear test iscrucial. Healthcare workers should also demonstrate sensitivity about this issue. We think that the importanceof the issue should be re-highlighted by organizing in-service training for female primary healthcare workers.Studies are warranted to determine the psychosociological factors that cause individuals to not have the test.     

Effects of Group Counseling Based on Health Belief Model on Cervical Cancer Screening Beliefs and Performance of Rural Women in Kaboudrahang,Iran

Objective: Pap smear test is an appropriate screening method for early diagnosis of cervical cancer and reduction of mortality. This study targeted effects of group counseling based on the Health Belief Model on cervical cancer screening practices of Iranian rural women. Method: This quasi-experimental study was conducted on 80 rural women under coverage of the health care centers in rural areas in the city of Kabudrahang, Iran, in 2015. The data collection tool was a researcher-made questionnaire covering demographic information, Health Belief Model (HBM) constructs and screening performance. Data were collected using a multi-stage sampling method. Group counseling was conducted based on the Health Belief Model and the GATHER steps in three sessions for the intervention group. Counseling included an introduction to cervical cancer, disease symptoms, warning signs and prevention approaches. Pap smear testing in both intervention and control groups was evaluated two months after the group counseling. Results: Before the intervention, there was no significant difference between both groups in the HBM constructs and performance. After the intervention, a significant difference was seen in the perceived susceptibility (P<0.001), severity (P=006), benefits (P=012), barriers (P<0.001), and self-efficacy (P=002). Two months after the intervention, 17 patients (42.5%) in the intervention group, and 4 patients (10%) in the control group had undergone a Pap smear test (P<0.001). Conclusion: Design and implementation of counseling programs based on the HBM can modify the beliefs of rural women regarding cervical cancer screening and increase their performance.     

Awareness of Cervical Cancer and Pap Smear Testing Among Omani Women

Background: In developed countries, awareness of cervical cancer screening is well documented. In contrast, in Oman as a developing country, public responses regarding cervical screening are unclear. This study aimed to assess the level of awareness about cervical cancer and Papanicolau (Pap) smear testing and to establish any correlations between knowledge and demographic factors among Omani women. Methods: In this cross-sectional survey, participants were divided into three groups: patients who attended the Outpatient Gynecology Department in Sultan Qaboos University Hospital (SQUH), Oman, female staff from SQUH, College of Medicine and College of Nursing at Sultan Qaboos University (SQU) and graduating female students at SQU. Data collection was through interview-based and online self-administered questionnaires. Cumulative scoring was used for data analysis. Results: There were 204 outpatients, 133 staff and 157 students. Outpatients (79.4%), staff (97.7%) and students (75.2%) had heard of cervical cancer. Nevertheless, their specific knowledge, regarding signs and symptoms, risk factors and Pap smear, was low at 38.7%, 35.3% and 7.6% among outpatients, staff and students, respectively. Some 39.9% of the married outpatients had adequate overall knowledge as compared to none of the single women. Educational level was found to be significantly associated with outpatient knowledge with the highest awareness levels among postgraduates and medical university graduates (61.5%). Conclusion: Specific knowledge of cervical cancer, its risk factors and cervical Pap smear is generally poor among Omani women. This lack of knowledge may be one of the contributing factors for the high incidence of cervical cancer in Oman relative to that in developed countries.     

Knowledge,Attitudes and Practice about Pap Smear Test among Women Living in Bojnourd,North East of Iran: a Population-Based Study

Background: The aim of the study was to assess the extent of knowledge, attitudes and practical behavior ofwomen in Bojnourd conerning the Pap smear test. Materials and Methods: This cross-sectional and populationbasedstudy was conducted with 1000 Iranian women aged 15-60 years old in Bojnourd city. In order to collect thedata, a validated questionnaire was provided in four sections covering demographic information and questionsabout knowledge, attitude and practice about the Pap smear. Statistical analysis was performed with the StatisticalPackage for Social Sciences (version 17.0) applying a 0.05 significance level. Results: Evaluation of knowledgeshowed that 146 women (14.6%) had very weak, and 594 women (59.4%) had weak knowledge. In contrast, mostof the women studied, 873 (87.3%), had a positive attitude toward the Pap smear test. According to the findings,375 women (37.6%) had done this test so far. Findings indicated that the extent of knowledge had a meaningfulrelationship with the attitude status (p<0.0001). Also, there was a meaningful relationship between knowledgeand practice, so that the weakest practice was seen in women who had weak knowledge (61.1%), (p<0.0001).Conclusions: According to findings of this research, most women do not have an appropriate knowledge aboutthe necessity of having the Pap smear test, so that only a low percentage of women had undergone this test.     

Management of Precancerous Cervical Lesions in Iran: A Cost Minimizing Study

Background: Cervical cancer is a common, preventable and manageable disease in women worldwide.Objectives: This study was conducted to determine the cost of follow-up for suspicious precancerous cervicallesions within a screening program using Pap smear or HPV DNA test through the decision tree. Materialsand Methods: Patient follow-up processes were determined using standard guidelines and consultation withspecialists to design a decision tree model. Costs of treatment in both public and private sectors were identifiedaccording to the national tariffs in 2010 and determined based on decision tree and provided services (visitsto specialists, colposcopy, and conization) with two modalities: Pap smear and HPV DNA test. The number ofpatients and the mean cost of treatment in each sector were calculated. The prevalence of lesions and HPV wereobtained from literature to estimate the cost of treatment for each woman in the population. Results: Follow-upcosts were determined using seven processes for Pap smear and 11 processes for HPV DNA test. The total costof using Pap smear and HPV DNA process for each woman in the population was 36.1$ and 174 $ respectively.Conclusions: The follow-up process for patients with suspicious cervical lesions needs to be included in theexisting screening program. HPV DNA test is currently more expensive than Pap smear, it is suggested that wemanage precancerous cervical lesions with this latter test.     

Cervical Cancer Screening Services at Tertiary Healthcare Facility: An Alternative Approach

Introduction: India fights massive cervical cancer burden. This article highlights an innovative feasible approachenabling tertiary hospitals to contribute to cancer prevention without compromising their primary mandate to providetreatment. Methodology: Since 1979, National Institute of Cancer Prevention and Research (NICPR) support a tertiaryhospital in cervical cancer screening through a satellite clinic. Record review of 5328 attendees of this clinic betweenJanuary-December 2016 was done. Pap-smear testing and reporting were performed by trained NICPR personnel. Patients’demographics, reproductive history, Pap-test date, cytology results were recorded and results were communicated torespective units for further management. Results: Among 5328 women screened, 2% (96/5328) had abnormal cytology,which included malignancy(33%; 32/96), Atypical Squamous Cells-Undetermined Significance(ASC-US) (20%;19/96), Atypical Glandular Cells(AGC) (23%; 22/96) with complaints of pain in lower abdomen 65.6%(59/90), whitedischarge per vaginum 46.7%(42/90) and backache 23.3%(21/90). In which, Muslims- 67% (65/96), illiterates- 58%(56/96). Age>35(p<0.001), parity>3(p<0.05), illiteracy (p<0.05), Muslim women (p<0.05) had positive association withabnormal cytology. Conclusion: Awareness about cervical cancer screening is the immediate need in resource-limitedcountries. Government hospitals in such countries should house dedicated preventive oncology unit for cancer screening.     

Personal and Socio-Cultural Barriers to Cervical Cancer Screening in Iran,Patient and Provider Perceptions: a Qualitative Study

Background: Although cervical cancer is preventable and early screening might decrease the associatedmortality, challenges faced by the women and health care providers can postpone early detection. This qualitativestudy aimed to establish patient and provider perceptions about personal and socio-cultural barriers for cervicalcancer screening in Mashhad, Iran. Materials and Methods: In the present study, which was conducted in 2012,eighteen participants, who were selected purposefully, participated in individual in-depth, semi-structuredinterviews, which were recorded, transcribed verbatim, and analyzed using conventional content analysis andAtlas-Ti software. Results: One theme and two categories were derived from data including: cognitive/behavioralfactors (lack of a community-based approach to cervical cancer, lack of awareness, wrong attitude and lackof health seeking behaviors) and socio/cultural issues (socio-cultural invasion, mismatch between tradition,modernity and religious, extra marital relationships and cultural taboos). Conclusions: Providing communitybased approach education programs and employing social policy are needed for preventing of cervical cancerin Iran.     

Cervical Cancer Screening: Patients Understanding in Major Hospitals in Malaysia

We studied women with cervical cancer to determine whether they had had a Pap smear within the 3 yearspreceding cancer development and their understanding of screening for this cancer. The study had 2 parts;Pathology Data and Survey Data. For pathology data, all cases of cervical cancer diagnosed in 2000-2006 wereretrieved from eight hospitals and Pap smear history was obtained from clinical records. For the Survey data;patients who were still undergoing treatment in some of these hospitals and three others were administeredstructured questionnaires to determine their awareness about screening. The results showed 1431 cases ofcervical cancer in women aged 25-85 were diagnosed in these hopsitals. Most had not had a Pap smear within 3years before cancer development. The percentage of patients who had had Pap smear ranged from 0-12%.Questionnaires were returned by 221 patients; 56.3% had none or only primary education and 61.1% had ahousehold income of RM1000 or less. Level of education and the household income were strongly associated(p<0.05) with knowledge and having had a Pap test. The main reasons cited for not having had a Pap smearwere “Never heard about it” (36.2%), “Shy” (10.4%), “Afraid to do it” (13.1%), “Think the test is not important”(8.1%) and “No encouragement from family” (4.5%). A large majority (95.9%) of the patients did not know theoptimal interval. In conclusion, a large number of cervical cancer patients had not had a Pap smear within 3years preceding cancer development and most had inadequate knowledge about this screening test.     

Cost-Effectiveness of HPV Vaccination in the Prevention of Cervical Cancer in Malaysia

Introduction: Cervical cancers (CC) demonstrate the second highest incidence of female cancers in Malaysia.The costs of chronic management have a high impact on nation’s health cost and patient’s quality of life that canbe avoided by better screening and HPV vaccination. Methodology: Respondents were interviewed from sixpublic Gynecology-Oncology hospitals. Methods include experts’ panel discussions to estimate treatment costsby severity and direct interviews with respondents using costing and SF-36 quality of life (QOL) questionnaires.Three options were compared i.e. screening via Pap smear; quadrivalent HPV Vaccination and combined strategy(screening plus vaccination). Scenario based sensitivity analysis using screening population coverage (40-80%)and costs of vaccine (RM 300-400/dose) were calculated. Results: 502 cervical pre invasive and invasive cervicalcancer (ICC) patients participated in the study. Mean age was 53.3 ± 11.21 years, educated till secondary level(39.39%), Malays (44.19%) and married for 27.73 ± 12.12 years. Life expectancy gained from vaccination is13.04 years and average Quality Adjusted Life Years saved (QALYs) is 24.4 in vaccinated vs 6.29 in unvaccinated.Cost/QALYs for Pap smear at base case is RM 1,214.96/QALYs and RM 1,100.01 at increased screening coverage;for HPV Vaccination base case is at RM 35,346.79 and RM 46,530.08 when vaccination price is higher. Incombined strategy, base case is RM 11,289.58; RM 7,712.74 at best case and RM 14,590.37 at worst case scenario.Incremental cost-effectiveness ratio (ICER) showed that screening at 70% coverage or higher is highly costeffective at RM 946.74 per QALYs saved and this is followed by combined strategy at RM 35,346.67 per QALYssaved. Conclusion: Vaccination increase life expectancy with better QOL of women when cancer can be avoided.Cost effective strategies will include increasing the Pap smear coverage to 70% or higher. Since feasibility andlong term screening adherence is doubtful among Malaysian women, vaccination of young women is a more costeffective strategy against cervical cancers.     

Awareness of Cervical Cancer Risk Factors and Screening Behaviour among Nurses in a Rural Region of Turkey

The demographic characteristics of nurses and knowledge on risk factors of cervical cancer, as well asawareness of symptoms and attitudes in terms of screening programmers such as Pap smear, were assessed in across-sectional survey of nurses working in public Health Cabins and Family Health Centers in the rural area ofIzmir, located in the western region of Turkey. Of the nurses who participated in the research, 69.1% (67) saidthat they had talked about cancer and cancer prevention with their families or friends; 60.8% (59) believed thattheir occupation was important for cancer prevention; 11.3% of the nurses had a history of cancer in theirfamilies; and 63.9% (62) thought that their knowledge about cervical cancer was adequate. There were nosignificant differences between knowledge or attitudes about cervical cancer risk factors or symptoms andscreening methods regarding age, marital status, years of experience (p>0.05). However, there was a statisticallysignificant relationship between having received a pap test and having a history of cancer in their family (p<0.05).In conclusion, this study has shown that most nurses knew about the Pap smear test as a cervical cancer screeningmethods. However, there were no significant differences between knowledge or attitudes about cervical cancerrisk factors or symptoms and screening methods regarding age, marital status, years of experience.     

Knowledge about Cervical Cancer Risk Factors and Pap Testing Behaviour among Turkish Women

Background: The aim of the paper was to examine knowledge about cervical cancer and in relation toPapanicolaou (Pap) testing among Turkish women. Methods: This cross-sectional study research was carriedout at Ege University Faculty of Medicine Hospital’s Obstetric and Gynecology Outpatient Clinic betweenMarch 1st, and May 30th, 2008 with 92 volunteer women who were sexually active and aged 25 to 61. Data wascollected through survey forms by interviews conducted by researchers. The form consisted of 30 questions andthree parts. Results: Of the women who participated in the research, 33.7 % were aged 42-49 and 44.6 % wereprimary school graduates. It was determined that 53.3 % of the women had long experience of living in aprovince and big city and that 82.6 % had middle income. Approximately two-thirds (68.5%) had received aPap test. The knowledge of the women within the scope of the research concerning cervical cancer risk factors(having a sexually transmitted disease, giving birth to many children, smoking, having sexual activity with aman who has had partners with a cervical cancer and having sexual intercourse at an early age) was found to berelated with their condition of having pap testing. Conclusion: The women’s condition of having pap testing isinfluenced by their age group, having a history of cancer in their family and having knowledge of cervicalcancer in advance (p <0.01). This research once again demonstrated that having knowledge is influential on thehabit of having pap testing. Taking this conclusion into consideration, it is crucial that information servicesaimed at the whole society, specifically women, should become widespread with the participation of healthworkers.     

Opportunistic Screening for Cervical Cancer in a Tertiary Hospital in Karnataka,India

The incidence and mortality of cervical cancer remains high in India even after sixty years of introductionof the Pap smear (cervical cytology) which is an effective means of identifying preinvasive lesions of carcinomacervix. The morbidity and mortality due to cervical cancer has come down drastically in countries with wellestablished screening programmes at national level. This study aims at screening women for cervical canceropportunistically during their visit to hospital and to study various types of neoplastic and non-neoplastic lesionsof the cervix by cervical smear study (Pap smear study). In the present study, a total of 350 cervical smearswere studied. The age of patients ranged from 19 years to 80 years with mean age being 37.5 years. Out of 350cases, the diagnosis of neoplasia was given in 43 cases and 258 cases were diagnosed as inflammatory smears.Forty-cases were normal and 9 cases were inadequate to evaluate. Forty-three patients who were found to haveneoplastic lesions on cytology were referred for further investigations like colposcopy and biopsy to confirm thediagnosis and avail proper treatment. Limitation of the present study was small sample size as all female patientsaged between 20 and 60 years visiting hospital were not included in the screening, other screening tests like VIA(visual inspection with acetic acid test) and HPV DNA (human papilloma virus) tests were not done. Until thetime centrally organised screening programmes for cervical cancer are established in India, arrangements shouldbe made for hospital based opportunistic screening for all women attending hospital. The cost effectiveness ofdifferent screening tests for cervical cancer should be evaluated.     

Cost-effectiveness Analysis of Cervical Cancer Screening Strategies Based on the Papanicolaou Smear Test in Korea

Background: Despite the increasing number of screening examinations performed for cervical cancer utilizingthe Papanicolaou smear test (Pap test), few studies have examined whether this strategy is cost-effective in Korea.Objective: This study was conducted to evaluate the cost-effectiveness of cervical cancer screening strategiesincorporating the Pap test based on age at the start and end of screening as well as screening interval. Materialsand Methods: We designed four alternative screening strategies based on patient age when screening was started(20 or 30 years) and discontinued (lifetime, 79 years). Each strategy was assessed at screening intervals of 1,2, 3, or 5 years. A Markov model was developed to determine the cost-effectiveness of the 16 possible cervicalcancer screening strategies, and this was evaluated from a societal perspective. The main outcome measures wereaverage lifetime cost, incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio(ICER). Results: Compared with various strategies comprising younger starting age, discontinuation age, andlonger screening intervals, strategies employing annual screening for cervical cancer starting at a target age of30 years and above were the most cost-effective, with an ICER of 21,012.98 dollars per QALY gained (with aKorean threshold of 30,000,000 KRW or US$27,272). Conclusions: We found that annual screening for cervicalcancer beginning at a target age of 30 years and above is most cost-effective screening strategy. Considering thepotential economic advantages, more intense screening policies for cervical cancer might be favorable amongcountries with high rates of cervical cancer and relatively low screening costs.     

Screening histories of women with CIN 2/3 compared with women diagnosed with invasive cervical cancer: a retrospective analysis of the Norwegian Coordinated Cervical Cancer Screening Program

Objective: This study compares the screening history for women with cervical intraepithelial neoplasia (CIN) 2/3 or adenocarcinoma in situ (ACIS) with women with different stages and subtypes of cervical carcinoma.Methods: An analysis of the Norwegian Coordinated Cervical Screening Program comparing all cases with a CIN 2/3/ACIS (N=8586) with all ICC (N=777) in the period 2000–2002. All Pap smears since 1992 were used to characterise detection mode and screening history. Multinominal regression models estimated the risk associated with detection mode and adequate Pap smear history.Results: A wide range of age at diagnosis, from 16 to 92 years of age was observed regardless of the stage of the disease. Fifty five percentage of the women diagnosed with CIN 2/3/ACIS had an adequate screening history. Of women diagnosed with SCC, 45.1% in stage I, and 10.5% in stage IV had an adequate history. The median age of women with CIN 2/3 (34 years) and squamous cervical carcinoma (SCC) stage I (37 years) given an adequate Pap smear history was not significantly different. For women with ACC, the proportion with adequate screening history was roughly 50% for all stages. After adjustment for detection mode and age, the OR for being diagnosed with ICC stage I compared to CIN 2/3 was 1.2 (95% CI: 1.0–1.5), while the OR of being diagnosed with ICC stage II–IV was 3.4 (95% CI: 2.3–4.8).Conclusions: Women with CIN 2/3 and ICC stage I were similar with respect to screening histories, i.e. detection mode and age at diagnosis, while women with ICC stage II–IV seldom had an adequate screening history and were diagnosed at a significantly higher age.