Search

Background: Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure., Objective: Identify socio-economic and demographic determinants for non-attendance in cervical screening., Methods: Design: Population-based case-control study. Setting: Sweden. Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30-60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6-8 years. The control group (N = 266,706) attended within 90 days of invitation. Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables. Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated., Results: Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01-2.11), with low education (adjOR 1.77; CI 1.73-1.81) and not cohabiting (adjOR 1.47; CI 1.45-1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06-4.35) to OR 0.54 (CI 0.52-0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors., Conclusion: County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Objectives: To analyse whether the prevalence of undiagnosed HIV among (1) all women in Sweden and (2) migrant women, diagnosed with cervical intraepithelial neoplasia grade 2 or worse CIN2 + reaches the threshold of 0.1%, which has been suggested to be cost-effective for HIV testing., Design: Population-based register study., Setting: Counties of Stockholm and Gothenburg, Sweden, 1990-2014., Population: All women, born between 1940 and 1990, with at least one cervical cytology or histology registered in the Swedish National Cervical Screening Register (NKCx)., Methods: Data were collected from the NKCx and the Swedish National HIV register. The proportion of women with undiagnosed HIV among women with CIN2 + compared with women with a normal/mildly abnormal cytology/histology was assessed., Main Outcome Measures: Proportion of women with undiagnosed HIV., Results: The proportion of undiagnosed HIV was higher among all women with CIN2 + than among those without CIN2 + : 0.06% (95% CI 0.04-0.08) versus 0.04% (95% CI 0.04-0.04); P = 0.017). Among migrant women, the proportion of undiagnosed HIV was higher among those with CIN2 + than among those without [0.30% (95% CI 0.20-0.43) versus 0.08% (95% CI 0.07-0.10); P < 0.001] and exceeded 0.1%, suggesting the cost-effectiveness of HIV testing. Women with undiagnosed HIV at the time of CIN2 + had a significantly lower nadir CD4 + T-cell count, as a measure of immunosuppression, compared with women without CIN2 + before HIV diagnosis (median nadir CD4, 95 cells/mm 3 versus 210 cells/mm 3 ; P < 0.01)., Conclusions: HIV testing should be performed in migrant women with unknown HIV status diagnosed with CIN2 + ., Tweetable Abstract: HIV testing should be performed in migrant women with unknown HIV status diagnosed with CIN2 + ., (© 2017 Royal College of Obstetricians and Gynaecologists.)

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., (Copyright © 2011 UICC.)

Objective: We sought to evaluate the management of women with abnormal cytology in terms of subsequent risk of invasive cervical cancer., Study Design: The screening histories of all invasive cervical cancer cases diagnosed in Sweden 1999-2001 and of 5 population-based controls per case were reviewed. In all, 159 patients and 258 control subjects aged < 67 years had an abnormal smear result 0.5-6.5 years prior to cancer diagnosis. The cervical cancer risk was estimated in relation to management by calculating odds ratios., Results: Histologic assessment of low-grade squamous abnormalities strongly reduced the risk compared to repeated cytology (odds ratio, 0.46; 95% confidence interval, 0.24-0.89). Delaying histologic assessment was also associated with a higher risk (odds ratio, 5.65; 95% confidence interval, 1.39-23.05). After high-grade squamous atypia, absence of any cytologic or histologic specimen was a major determinant of cancer risk (odds ratio, 12.52; 95% confidence interval, 1.42-infinitive)., Conclusion: For adequate protection against invasive cervical cancer, further assessment with histology must be recommended also for women with low-grade squamous abnormalities.

Background: The effectiveness of cervical cancer screening programs differs widely in different populations. The reasons for these differences are unclear. Routine and comprehensive audits have been proposed as an ethically required component of screening. We performed a nationwide audit of the effectiveness of the Swedish cervical cancer screening program., Methods: We identified all invasive cervical cancer cases that were diagnosed in Sweden from January 1, 1999, through December 31, 2001, and had been reported to the Swedish Cancer Registry (n = 1230 cases). We verified the diagnoses by histopathologic rereview and matched each case subject to five (population-based) age-matched control subjects who were identified from the National Population Register. The Pap smear screening histories for case and control subjects were reviewed for a 6-year period using the National Cervical Cancer Screening Register, which contains data on essentially all relevant cytological and histological diagnoses in Sweden. Odds ratios (ORs), and their 95% confidence intervals (CIs), of cervical cancer according to screening history were calculated in conditional logistic regression models. All statistical tests were two-sided., Results: Women who had not had a Pap smear within the recommended screening interval had higher risk of cervical cancer than women who had been screened (OR = 2.52, 95% CI = 2.19 to 2.91). This risk was similarly increased for all age groups (P(homogeneity) = .96). The risk for non-squamous cell cervical cancers (OR = 1.59, 95% CI = 1.20 to 2.11) was also increased. Women who had not had a Pap smear within the recommended screening interval had a particularly high risk of advanced cancers (OR = 4.82, 95% CI = 3.61 to 6.44). Among women who had been screened within the recommended interval, those with abnormal Pap smears had a higher risk of cervical cancer than those with normal smears (OR = 7.55, 95% CI = 5.88 to 9.69) and constituted 11.5% of all women with cervical cancer., Conclusions: Nonadherence to screening intervals was the major reason for cervical cancer morbidity. The screening program was equally effective for women of all ages and was also effective against non-squamous cancers.

Background: Organized Papanicolaou (Pap) screening has markedly reduced the incidence of cervical squamous cell carcinoma (SCC). However, the potential for overtreatment of precursor lesions is quite high for SCC, and the effectiveness of Pap screening for prevention of cervical adenocarcinoma is questionable., Methods: Using the nationwide, virtually complete Swedish Cancer Register, we analyzed standardized incidence rates for SCC in situ (CIS), SCC, adenocarcinoma in situ (AIS) and adenocarcinoma, between 1968 and 2002. For each county, we calculated Spearman correlations between incidence of in situ lesions and incidence of invasive cancer, 5, 10, and 15 years later. We also used generalized estimating equation (GEE) models to compare adjusted estimates for associations between in situ incidences and invasive carcinomas over counties., Results: The overall decrease in SCC incidence in Sweden following the introduction of cervical screening confirms the beneficial nature of cervical screening on SCC incidence over the last 30 years. A similar benefit was not apparent for adenocarcinoma. GEE estimates for the relative change in SCC for an increase of 100 CIS cases per 100,000 women-years were 1.05 for the 5-year and 1.02 for the 10-year lag periods. For adenocarcinoma and AIS, similar analyses gave corresponding estimates of 1.17 for the 5-year and 1.08 for the 10-year lag periods. The lack of an inverse correlation suggests that increased reported incidence of CIS in certain counties did not forecast a reduction in SCC for those counties., Conclusion: Our data confirm the effectiveness of Pap smear screening in reducing the incidence of SCC, but suggest no clear benefit on adenocarcinoma. Our data also suggest that relaxed histopathologic criteria for diagnosis of cervical CIS may increase its recorded incidence with no measurable benefit in the reduction of invasive cancer.

Objectives: Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved., Methods: We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities., Results: The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) -0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9-10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9-35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled., Conclusions: Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives.

Previous studies on whether signs of infection in Pap smears imply a risk factor for preterm delivery are conflicting. In a large population-based study, we combined information from the Swedish Medical Birth Register and the Swedish Pap Smear Screening Register to investigate whether signs of infection in Pap smears increase the risks of adverse pregnancy outcomes. Logistic regression analyses were used to estimate odds ratios (OR) for antepartum death, preterm or small-for-gestational-age delivery. The presence of Coccobacilli or Trichomonas vaginalis in Pap smears increased the risk of small-for-gestational-age delivery (OR 1.3 and 1.4, respectively). Signs of infection in Pap smears were generally not associated with an increased risk of antepartum death or preterm birth. However, the presence of Coccobacilli in Pap smears within 4 weeks before delivery was associated with a more than fourfold increase in risk of very preterm delivery (< or =31 weeks, OR 4.7). This indicates that if Coccobacilli are detected in Pap smears during the second trimester, antibacterial treatment may lower the risk of very preterm delivery.

Objectives: To investigate how attitudes and beliefs about Pap smear screening affect women's choice to participate in organized or opportunistic screening., Methods: Telephone interviews were conducted with 430 (69.0%) non-attenders and 514 (80.7%) attenders to Pap smear screening, sampled from a population-based database. The interviews were conducted during 1998 in Uppsala County, Sweden., Main Outcome Measure: odds ratios (OR) and 95% confidence intervals (CI)., Results: Non-attendance was negatively associated with perceived severity of cervical cancer compared to other malignancies (OR = 1.9, 95% CI 1.1-3.4) as well as with satisfactory benefits (OR = 0.7, 95% CI 0.6-0.8), but positively associated with time-consuming and economical barriers (OR = 1.2, 95% CI 1.1-1.5 and OR = 1.7, 95% CI 1.2-2.5, respectively). Non-attendance was also negatively associated with anxiety, but was of borderline significance (OR = 0.9, 95% CI 0.8-1.0). The results were strengthened with increasing time since last smear or if self-reported attendance status was used instead of true attendance. Non-attenders kept holding harder to their preferences than did attenders, stating they would not participate if their preferences were not met., Conclusions: Important differences in attitudes and beliefs exist between non-attenders and attenders in Pap smear screening. Rather than being emotional, the main barriers are either practical or rooted in misunderstandings and lack of relevant information. These insights offer opportunities to increase attendance rates considerably.

Background: With an improved compliance with screening a larger reduction of cervical cancer incidence would be within reach. We aimed at investigating why certain women do not attend Pap smear screening and at validating the reliability of self-reported screening., Methods: In 1998 in the county of Uppsala, Sweden, information was collected through telephone interviews with 430 nonattendees and 514 attendees to Pap smear screening, who were all sampled from a population-based database. The women's recall of attendance was validated against the database. The main outcome measures used were odds ratios (OR) and 95% confidence intervals (CI)., Results: Non-attendance was positively associated with nonuse of oral contraceptives (OR = 3.56, 95% CI 2.18-5.83), seeing different gynecologists (OR = 1.90, 95% CI 1.34-2.70), and seeing a physician very often (OR = 3.12, 95% CI 1.45-6.70) or not at all (OR = 1.78, 95% CI 1.09-2.90). Frequent condom use (OR = 1.88, 95% CI 1.02-3.47), living in rural/semirural areas (OR = 1.55, 95% CI 1.07-2.21), and not knowing the recommended screening interval (OR = 2.16, 95% CI 1.20-3.89) were all associated with nonattendance, whereas socioeconomic status was not, when tested in a multivariate model. Among the nonattendees, 57% underestimated the time lapse since last smear., Conclusions: Seeing a gynecologist on a regular basis and information guiding women to have a Pap smear on their own initiative are important factors for recurrent screening. Therefore, information should be given to all women about the purpose and benefits of Pap smear testing. Self-reports on screening should be treated with caution., (Copyright 2001 American Health Foundation and Academic Press.)

Cytologic screening for cervical cancer has proven to be beneficial in many countries, although the value of this intervention in women older than 50 years remains controversial. The purpose of this study was to investigate the efficiency of detecting cancer in situ by means of a cytologic smear at different ages, with special emphasis on the benefit of screening in women above the age of 50. We analyzed 466,275 smears taken in an open cohort of 118,890 women in Sweden between 1969 and 1988. The number of cancers in situ detected per 1,000 smears, the detection ratio, was used as an outcome measure in univariate analyses and in multivariate regression models. Cancer in situ was detected in 1,076 women in the study cohort. The detection ratio peaked at ages 30 to 34 and decreased heavily during the next 15 years of age. The efficiency of taking smears at ages above 50 was only 20 per cent (OR, 0.19; 95% CI, 0.14-0.26) of that at ages 30 to 34. These results were not changed when adjusting for time period and time interval since the previous smear. In spite of a high incidence of invasive cervical cancer in older women, the benefit of cytologic screening to detect cancer in situ above the age of 50 is uncertain.

Cervical cancer incidence and mortality can be reduced by removal of precursor lesions detected at cytological screening. Organised screening, i.e. regular invitation of defined target groups, is generally considered more effective than opportunistic screening. The latter method however, is predominant in most settings. There is no scientific basis for advocating one type of screening or the other. Our aim was to compare the two types and to analyse their efficiency. We analysed 466,275 smears taken in an open cohort of 118,890 women during 1969-88. A computerised database permitted standardised classification of all smears and complete ascertainment of cancer in situ through record linkage. The number of in situ cancers detected per 1000 smears, the detection ratio, was used as an outcome measure both in univariate analyses and in multivariate logistic regression models. Cancer in situ was detected in 1076 women in the study cohort, with a detection ratio of 3.0 at organised and 2.1 at opportunistic screening, yielding an unadjusted odds ratio of 0.69 (95% CI 0.61-0.79). After adjustment for age and time period, the probability of detecting cancer in situ was around 25% higher with opportunistic than with organised screening (OR = 1.26; 95% CI 1.09-1.46). This difference in favour of opportunistic screening was most pronounced in the first 10 year period and disappeared during the last decade. The difference in efficiency between organised and opportunistic screening in the detection of cancer in situ was slight, if any. The dogma that organised screening is significantly more efficient than the opportunistic type needs reconsideration.