Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.     

Effect of organised screening on cervical cancer incidence and mortality in Finland, 1963-1995: recent increase in cervical cancer incidence.

A nation-wide screening programme for cervical cancer started in Finland gradually from 1963 onwards. By the beginning of the 1990s, there had been a decrease of 80% both in the age-adjusted incidence of and mortality from cervical cancer. To describe the recent patterns in cervical cancer incidence and mortality and evaluate their differentials in relation with the organised screening activities, we have updated the material on the cervical cancer incidence and mortality as well as mass-screening activities up to the year 1995. Based on the files of the Finnish Cancer Registry, there is a striking increase of about 60% in the incidence of cervical cancer during the last 4 years of the study period among women below 55 years of age. The mortality rates are still decreasing. There is no overall decrease over recent years in the coverage of the programme invitations or smears taken. Incidence of invasive cancer and of moderate and severe dysplasia as detected in mass screening have increased. As to the interpretation, changes in the risk factors, such as in sexual behaviour and smoking habits, over the decades might partly explain increasing trends in cervical cancer incidence. As the change in incidence was relatively abrupt, inadequacies or changes in the effectiveness in the screening programme, particularly among young women, may also have contributed. Expanding the coverage of and attendance in the pap-screening programme among women in young target ages would still be effective. Increasing emphasis on quality assessment in screening is also needed.     

Trends in Incidence and Mortality Rates of Squamous Cell Carcinoma and Adenocarcinoma of Cervix - Worldwide

The objective of the present paper is to summarize and quantify the trends in incidence and mortality ratesof cervical squamous cell carcinoma (SCC) and adenocarcinoma (AC) worldwide. All indexed publications,which provided information on time trends in incidence or mortality rates of cervix cancer, published duringthe past 12 years were included. The details of studies have been identified through searches on the MEDLINEdatabase. Cytology screening as well as changes in socio-economic profile has led to declines in cervical SCCincidence and mortality rates worldwide. Higher percentage decline in SCC is observed in countries whereorganized screening programmes are available. The results suggested that Pap smear screening has played asignificant role in the reduction in SCC in the US, Canada, New South Wales, and in almost all Europeancountries (except in Ireland) as well as in some of the Asian countries. Increasing incidence and mortality ratesof cervical AC has reported in many countries such as the US, Canada, UK, Iceland, Sweden, England, Spain,Finland, Slovakia, Slovenia, the Netherlands particularly among young women. However the increase was mainlyin earlier periods till 1995 and stable or declining trends in cervical AC have been observed in later periods inmany of the above countries such as the US, UK, Canada, Sweden. The increasing risk of AC suggested a majorrole for an increasing prevalence of persistent oncogenic HPV infection and its cofactors, whereas the downturnin period effects in several countries during the 1990s provided evidence that cytology screening is detectingmore preinvasive ACs than in previous decades and suggested that screening might be starting to have a protectiveimpact on AC. The decline in AC incidence might be due to improved specimen collection as well as due toincreased awareness of AC pre-cursors among cytopathologists and clinicians, improvements in laboratorytraining and quality assurance. In conclusion, cytology screening in combination with HPV screening for highriskHPV types may maximize the possibilities of having early cervical lesions detected and treated.     

Cervical cancer screening programme in Finland

In Finland, the organised screening programme for the prevention of cervical cancer has been run for over 30 years and has contributed to a 70-80% decrease in the age-adjusted cervical cancer incidence, as well as a reduction in mortality rates. In this article, we describe the operational details of the organised programme - how the target population is defined, how the invitations are done, how smear tests are collected and analysed, how referrals to confirmation and treatment are conducted, and we also provide recent data on the extent and main screening results. The Finnish programme has led to net savings when assessed for its cost-effectiveness. The results encourage the continuation of the screening programme. By introducing modern screening technologies and more systematic quality control activities in the programme, and by expanding the coverage and compliance we expect to further increase the impact of the programme.     

Does lowering the screening age for cervical cancer in The Netherlands make sense?

Recommendations for the age to initiate cervical cancer screening should be directed towards maximum detection of early cervical cancer. However, the screening programme should do more good than harm. The aim of this analysis was to determine whether the target age for cervical cancer screening should be lowered in view of apparent increases in new cases of invasive cancer below age 30 and in age group 30-44 years in The Netherlands. Therefore, all cervical cancer cases diagnosed between January 1, 1989 and December 31, 2003 were selected from the nationwide population-based Netherlands Cancer Registry. For age group 25-39 years, incidence data were also available for 2004 and 2005. To describe trends, the estimated annual percentage of change and joinpoint analysis were used. Between ages 25 and 28 years, the absolute number of new cases of cervical cancer annually has varied between 0 and 9 per age. Significantly decreasing trends in incidence were observed for age groups 35-39 and 45-49 (p < 0.0001 and p = 0.01, respectively). The annual number of deaths fluctuated with a decreasing trend for age groups 30-34 and 35-39 years (p = 0.01 and p = 0.03, respectively). Because the incidence and mortality rates for cervical cancer among women younger than 30 are low and not increasing, lowering the age for cervical cancer screening is not useful at this time. Although the number of years of life gained is high for every case of cervical cancer prevented, the disadvantages of lowering the screening age would be very large and even become disproportionate compared to the potential advantages.     

Low risk of cervical cancer during a long period after negative screening in the Netherlands

A condition for effective cervical cancer screening is a low incidence of cervical cancer after negative screening compared to that in the absence of screening. This relative risk was studied for the period 1994-1997 in the Netherlands and compared with previous studies. All cases of invasive cervical cancer diagnosed from 1994 to 1997 in the Netherlands were related to woman-years at risk, stratified by age, number of preceding negative screenings and time since the preceding negative screening. These incidence rates were compared with that before screening started in the Netherlands. The relative risk increases from 0.13 in the first year after screening to 0.24 after more than 6 years after screening for women with one previous negative screening. These figures reduce to 0.06 and 0.18, respectively, for women with two or more previous screenings. However, these estimates are less favourable when account is taken of the likely decrease in risk for cervical cancer in the period studied. Our data show a low relative risk of cervical cancer for several years following the last negative Pap smear. However, the denominator of the relative risk, that is, the incidence without screening, may have been overestimated. This applies also to the IARC multicountry study, and may have caused too optimistic expectations about the effectiveness of cervical cancer screening.     

Women who participate in spontaneous screening are not at higher risk for cervical cancer than women who attend programme screening

Up to 1995, programme screening for cervical cancer in The Netherlands was targeted at women between 35 and 54 years of age at 3-yearly intervals. Spontaneous screening in addition to programme screening was common practice. Our aim was to compare the underlying risk for cervical neoplasia for women involved in both types of screening. From the national pathological database, we retrieved all primary smears (n=693318) taken in 1994 in The Netherlands. Among the smears registered for screening purposes (39%), 79% was taken within the mass screening programme and 21% was taken for spontaneous screening. The underlying risk was studied from the detection rates of histologically confirmed severe dysplasia or worse, using a multivariate loglinear model, including age and screening history. The detection rate of at least severe dysplasia, adjusted for age and screening history, was equal for women who had a spontaneous smear and for those who had a programme smear (odds ratio (OR): 0.97; 95% Confidence Interval (CI): 0.84-1.14). In our data, women participating in spontaneous screening were not at a higher risk for cervical cancer than women who used programme screening. Therefore, all asymptomatic women in the Netherlands should follow the general guidelines for age-range and screening-interval.     

Cervical cancer screening in Korea: report on the National Cancer Screening Programme in 2008

The National Cancer Screening Programme (NCSP) began in 1999. The purpose of this report is to evaluate the results of the NCSP for cervical cancer in 2008 and to present essential evidence associated with the cervical cancer screening programme in Korea. Screening results were obtained from the National Cancer Screening Information System. Participation rates and recall rates were calculated with 95% confidence intervals (CIs). The target population of the cervical cancer screening programme in 2008 was 4,701,167 Korean women aged 30 and over, 1,208,581 of whom underwent Papanicolaou (Pap) smear tests (25.7% participation rate). The recall rate was 0.41% (95% CI, 0.40 to 0.42). Although efforts to facilitate participation and to reduce disparities in cervical cancer screening among Korean women are needed, the results do provide support for evidence-based strategies for control of cervical cancer in Korea.     

A screening programme for cervical cancer that worked

In three of the Nordic countries there are nationwide population based screening programmes for cervical cancer. These organized programmes have resulted in a substantial decrease in the incidence of and mortality from cervical cancer. In Finland the reduction in the incidence due to screening has been about 60-70% and it was most substantial for women around the ages of 35 to 50 years, which were screened most intensively. Similar changes occurred in the mortality. It seems that the prerequisites for a successful programme are, for example, to identify the target population, to send personal invitations to attend the screening and to give the results to the women screened. Quality control and evaluation of the programme are also assumed to be part of the programme. The programmes are consuming few resources. In Finland screening is repeated every five years, resulting in only six or seven smears in a lifetime.     

Trends in cervical cancer and carcinoma in situ in Great Britain

Doubts have frequently been expressed about the effectiveness of the screening programme for cervical cancer in Britain. These doubts have been reinforced as a result of recent increases in mortality from this disease among younger women. In this paper we discuss trends in registration and mortality data, relate these to the level of screening, and conclude that screening may in fact have had a considerable impact on mortality rates. There is good evidence that in some age groups there has been a large increase in the incidence of carcinoma in situ of the cervix; it seems likely that the potential increase in cervical cancer incidence and mortality may have been partially prevented as a result of the screening programme. The extent of this effect cannot be quantified precisely because of uncertainties concerning the natural history of cervical cancer, differences in risk for different cohorts, and the possible effects of other factors. It is likely that incidence rates will continue to change, and it will be necessary to monitor these and the screening programme with some care in order to make the best use of the resources available for cervical cytology.     

Trends in cervical and breast cancer in Iceland. A statistical evaluation of trends in incidence and mortality for the period 1955-1989, their relation to screening and prediction to the year 2000

The time trends in incidence and mortality from cervical cancer and breast cancer in Iceland, from 1955 to 1989, were analyzed by fitting curvilinear regressions to the age-standardized rates. The effect of the screening was evaluated by comparing the curvature of the fitted regression lines and changes in screening activity. The incidence and mortality rates for both cancer types were predicted up to the year 2000. At the commencement of cervical cancer screening in 1964, both the incidence and mortality rates were on the increase. After 1970, both rates decreased significantly. Assuming that regular attendance at screening will be 85%, it is predicted that the incidence and mortality rates will level out at about 7.5 and 2 cases per 100,000 women per year, respectively, by the year 1995 and remain at that level. The incidence of breast cancer has increased steadily since 1955. A sharp rise has been observed since 1987, due to screening with mammography. The mortality rate has shown small but significant fluctuations with time. The incidence rate is predicted to increase at the same rate as before 1987 (i.e. at 1.1 cases per 100,000 women per year), but at a slightly higher level and is predicted to reach 84 cases per 100,000 women per year by the year 2000. Breast cancer mortality is predicted to decrease to about 17 cases per 100,000 women per year by 1995 and to remain at that level.     

Effective cervical cytology screening programmes in middle-income countries: the Chilean experience

OBJECTIVE: To demonstrate that an effective cervical cancer screening programme based on the Papanicolaou (Pap) smear can be organized in a middle-income country, such as Chile. METHODS: The cervical cytology screening programme in Chile is evaluated by comparing process measures and cervical cancer mortality before and after its reorganization in 1987. FINDINGS: Two decades of opportunistic annual screening for cervical cancer from the mid-1960s to the mid-1980s did not reduce cervical cancer mortality in Chile. In 1987, a public health oriented program was launched, based on screening women aged 25-64 every 3 years, rather than the annual screening of low risk women attending family planning clinics that gathered mainly women less than 25 years of age. The reoriented program emphasized the optimization of existing resources, the timeliness of diagnosis and treatment, reliability of the Pap smear and low cost screening promotion strategies at the community level. More than 80% of women with abnormal Pap smears received prompt medical attention and 100% of the public laboratories were subject to external quality control. According to biannual national surveys, coverage by Pap smear screening in the target group rose from 40% in 1990 to 66% in 1996. The age adjusted cervical cancer mortality rate decreased from 12.8 in 1980 to 6.8 per 100,000 women in 2001. CONCLUSIONS: Improved organization of the national cervical cancer screening programme in Chile and more efficient use of existing resources resulted in a decrease of cervical cancer mortality.     

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.     

Decline in Cervical Cancer Incidence and Mortality in New South Wales in Relation to Control Activities (Australia)

Background To examine time trends in cervical cancer incidence and mortality in NSW women aged ￥20 years in relation to important health service initiatives and programs. Methods Data on cervical cancer incidence and mortality were obtained from the NSW Central Cancer Registry for 1972–2001, and corresponding annual populations obtained from the Australian Bureau of Statistics. Direct age-standardised rates in the ￥20 year population were calculated using the 2001 NSW census population as standard. Proportional reductions in incidence and mortality since 1972–1974 were also calculated and related to key health service factors and to published NSW 5-year cervical cancer relative survival for similar periods. Results Declines in cervical cancer incidence (−10%) and mortality (−20%), and increased degree-of-spread specific survival following the introduction of universal health care in 1975 suggest effects of greater access to Pap screening, earlier access to diagnosis and treatment services, and improved effectiveness of treatment. Incidence plateaued during the 1980s, but mortality fell further (−7%) due to an increased proportion of localised cancers (without change to degree-of-spread specific survival). The 1980s mortality reduction was a consequence of earlier diagnosis and/or secondary prevention, not improved treatment effectiveness or reduced incidence. A marked and sustained incidence decline to 2001 (−35%) occurred after the introduction of the NSW Cervical Screening Program in 1992. This was followed 3 years later by a sustained mortality decline (−20%). During the 1990s survival across all degrees of spread remained unchanged and the mortality reduction was due entirely to reduction in incidence. Conclusions The substantial reduction of cervical cancer incidence and mortality in NSW over the last 3 decades is associated with important health service interventions that relate to control of cervical cancer, particularly the implementation of a population-based organised cervical screening program.     

Organised vs. spontaneous Pap-smear screening for cervical cancer: A case-control study.

To compare the effect of organised pap-smear screening for cervical cancer with that of the spontaneous one on the incidence of invasive cervical cancer, we performed a case-control study within the catchment area of the Helsinki University Hospital (Helsinki, Finland). The study material consisted of 179 incident cases of invasive cervical cancer and 1,507 population controls. Data on lifetime pap smears before the year of the cancer diagnosis were collected using a self-administered questionnaire. The questionnaire information was obtained for 82% of the cases and 73% of the controls. The main outcome measure was relative risk of invasive cervical cancer among those with history of organised or spontaneous screening compared with risk among those with no history of screening for cervical cancer, measured as odds ratios (OR) with 95% confidence intervals (CI) and computed with logistic regression. Odds ratio of invasive cervical cancer among those who participated in the organised screening programme was 0.38 (CI 0.26-0.56) whereas any lifetime spontaneous pap smear had an OR value of 0.82 (CI 0. 53-1.26), in terms of unit risk for those not subjected to any screening and adjusted for age and the other type of the screening activity. Our results indicate that the substantial decrease in the incidence of and mortality due to cervical cancer in Finland is mainly due to the organised mass-screening.     

Diverging breast cancer mortality rates in relation to screening? A comparison of Nijmegen to Arnhem and the Netherlands, 1969-1997

Age-standardised breast cancer mortality rates have been stable for decades. However, rates have started to decline in several Western countries. In countries where population-based screening programmes for breast cancer were introduced in the late 1980s or early 1990s, the key question now is to what extent screening is responsible for the reported declines in mortality. This study compares breast cancer mortality rates in Nijmegen, where a screening programme for breast cancer was introduced in 1975, to a control city, Arnhem, and to the Netherlands as a whole over a 20-year period. Age-standardised breast cancer mortality rates as well as age-standardised mortality ratios were calculated for successive calendar years from 1969 to 1997. Further, a tailor-made period-cohort-group Poisson regression model was fitted. Figures displaying age-standardised mortality rates and ratios showed inconclusive patterns with regard to the expected impact of screening. Depending on when mortality rates were allowed to deviate between populations, the period-cohort-group analysis indicated a non-significant 6% to 16% reduction in breast cancer mortality after 2 decades in favour of the Nijmegen female population. Possible explanations are discussed as to why the mortality reductions reported by randomised trials might not be observed in a public health screening programme, such as the Nijmegen programme, evaluated by comparisons of geographical trends.     

Decreased rates of advanced breast cancer due to mammography screening in The Netherlands

The effect of the implementation of the Dutch breast cancer screening programme during 1990-1997 on the incidence rates of breast cancer, particularly advanced breast cancer, was analysed according to stage at diagnosis in seven regions, where no screening took place before 1990. The Netherlands Cancer Registry provided detailed data on breast cancer incidence in 1989-1997 by tumour stage, age and region. Annual age-adjusted incidence rates of all breast cancers and advanced cancers, defined as large tumours T2+ with lymph node and/or distant metastases, were compared with rates in 1989. In general, breast cancer incidence rose strongly in the early 1990s, especially in the age category 50-69 years (estimated annual percentage change (EAPC) 4.25; 95% CI 1.70, 6.86). The increase was mainly due to the increase in small T1 cancers and ductal carcinoma in situ. However, in women aged 50-69, advanced cancer incidence rates showed a significant decline by 12.1% in 1997 compared with 1989 (EAPC -2.14, 95% CI -3.47, -0.80), followed by a breast cancer mortality reduction of similar size after approximately 2 years. We confirm that breast cancer screening initially leads to a temporary strong increase in the breast cancer incidence, which is followed by a significant decrease in advanced diseases in the women invited for screening. It is evident that breast cancer screening contributes to a reduction in advanced breast cancers and breast cancer mortality.     

Neuroblastoma trends in Osaka,Japan, and Great Britain 1970-1994, in relation to screening

Japan pioneered and has maintained a nationwide mass screening programme for neuroblastoma since 1985 without prior evaluation among a target population. Convincing population-based evaluation of the ongoing programme has also been very limited because a population-based registry for childhood cancer has not been in operation. This report describes trends in incidence of and mortality from neuroblastoma in Osaka Prefecture, Japan, using Great Britain as an external control, between 1970 and 1994. Incidence and mortality rates were comparable between the 2 areas before the beginning of screening in Osaka. However, incidence rates were markedly increased in Osaka, especially among children younger than 1 year, from 25.9 per million children during 1970-1979 to 240.2 during 1991-1994, while age-standardized incidence rates for metastatic tumours among children aged 1 year or above did not decrease after introduction of the programme. Age-standardized mortality rates per million were unchanged at 3.9 (1970-1979) and 4.1 (1991-1994) in Osaka and 5.7 (1971-1979) and 5.0 (1991-1994) in Great Britain. Cumulative incidence rates among those up to 15 years old progressively increased from 103.4 per million (1970-1979) to 350.0 (1991-1994) in Osaka, though cumulative mortality rates did not decrease: 52.0 and 57.5, respectively. Corresponding figures in Great Britain were 101.0, 115.1, 78.6 and 70.1, respectively. The present findings show little beneficial effect of the screening programme.     

Breast cancer trends: opportunistic screening in Austria versus controlled screening in Finland and Sweden.

The objective of the study was to compare the trends of incidence and of mortality of breast cancer in Austria, Finland and Sweden, where different mammography screening strategies (opportunistic versus controlled) are applied. Furthermore, to find out whether a change in screening strategies would be feasible for Austria. Age-standardized incidence rates (1983-2000) and mortality rates (1980-2001/2) were analysed. Furthermore, the annual per cent change and the annual rate change (annual rate change=+/-n/100,000 per year) and the 95% confidence interval were calculated. In all three countries, incidence rates increased significantly (Austria +26.4%, Finland +86.7%, Sweden +38.8%) during the period analysed (P<0.01). The annual per cent change and the annual rate change in Austria (1.57 and 1.56, respectively) are below the annual per cent change and the annual rate change in Finland (3.38 and 3.49, respectively) and in Sweden (1.80 and 2.19, respectively) for the period analysed. Total breast cancer mortality decreased significantly in Sweden since 1980 (-20.5%, P<0.01), in Finland since 1988 (-18.3%, P<0.05) and in Austria since 1990 (-19.8%, P<0.01). The annual per cent change and the annual rate change in Austria (-1.81 and -0.59, respectively) are below the annual per cent change and the annual rate change in Finland (-0.57 and -0.16, respectively) and in Sweden (-1.02 and -0.28, respectively) for the period analysed. In conclusion, despite its unsophisticated opportunistic screening, Austria does well in comparison with countries operating organized breast cancer screenings.     

No increased risk for cervical cancer after a broader definition of a negative Pap smear

The definition of minimal relevant Pap smear abnormality is crucial for balancing the beneficial effects of screening (prevented mortality) with negative side-effects (the high positivity rate). After inflammation ceased to be defined as a borderline abnormal smear outcome in The Netherlands in 1996, the proportion of these smears dropped from 10% to less than 2%. Because this may have caused a loss in smear sensitivity, we analysed the changes in the incidence of cervical cancer after a negative Pap smear. All negative smears made at ages 30-64 in 1990-1995 (n = 1,546,252) and 1998-2006 (n = 3,552,716), registered in the national registry of histo- and cytopathology (PALGA), were followed for up to 9 years. During follow-up of the 1990-1995 smears, 377 women developed cervical cancer within 5,232,959 woman-years at risk, while during the follow-up of the 1998-2006 smears, 619 women developed cervical cancer within 11,210,675 woman-years at risk. The cumulative incidence after the definition change was not significantly higher than before: e.g. at 6 years, the cumulative incidence for smears made in 1990-1995 was 46 per 100,000 (95% CI: 41-52), and for smears in 1998-2006 was 48 per 100,000 (95% CI: 43-54), p = 0.59. The hazard ratio for 1998-2006 compared to 1990-1995 adjusted for age, number of previous negative smears and history of abnormalities was 0.90 (95% CI: 0.78-1.03). In The Netherlands, a setting with high-quality cytological screening, treating smears with only signs of inflammation as negative leads to a considerably lower positivity rate without increasing the risk for cervical cancer after a negative smear.