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Objective: To assess the health-related quality of life (HRQoL) impact of cervical cancer screening in women with normal test results., Design: Questionnaire study., Setting: Maastricht, the Netherlands., Population: A cohort of 789 women were followed from screening invitation until after the receipt of screening results. A female age-matched reference group (n=567) was included., Methods: Questionnaires were sent to the home address of the women before screening, after screening, and again with the screening results., Main Outcome Measures: Generic HRQoL (SF-12, EQ-5D), generic anxiety (STAI-6), screen-specific anxiety (PCQ), and potential symptoms and feelings related to the smear-taking procedure., Results: A total of 60% of screening participants completed questionnaire 1(n=924): 803 of these women granted permission to access their files; 789 of these 803 women had normal test results (Pap 1), and were included in the analyses. Generic HRQoL (SF-12, EQ-5D) and anxiety (STAI-6) scores were similar in the study and reference groups. Before screening, after screening, and also after the receipt of test results, screening participants reported less screen-specific anxiety (PCQ, P<0.001) than the reference group (n=567), with differences indicating clinical relevance. 19% of screening participants were bothered by feelings of shame, pain, inconvenience, or nervousness during smear taking, and 8 and 5% of women experienced lower abdominal pain, vaginal bleeding, discharge, or urinary problems for 2-3 and 4-7 days, respectively, following the Pap smear., Conclusion: The reduced levels of screen-specific anxiety in screening participants, possibly indicating reassurance, are worthwhile addressing in more depth. We conclude that although considerable numbers of women reported unpleasant effects, there were no adverse HRQoL consequences of cervical screening in women with normal test results., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

The Dutch Minister of Health, Welfare and Sportintends to implement Human papillomavirus (HPV) vaccination for 12-year-old girls and catch-up vaccination for 13- 16-year-old girls, as part of the National Immunisation Programme from September 2009 onwards. However, due to a well-organised screening programme, cervical cancer is not an important public health problem in the Netherlands any more, which limits the possible impact of HPV vaccination. Vaccine trials thus far have involved a relatively small number ofparticipants with limited follow-up, so the efficacy of the vaccine in preventing cervical cancer is not yet known. There are no data on frequency and severity of possible adverse events and the vaccine has not yet been tested in the intention-to-vaccinate group of 12-year-old girls. Even when we assume that HPV16/18-related cervical cancer is prevented on a lifelong basis, the cost-effectiveness ratio of HPV vaccination is estimated not to be favourable. In conclusion, HPV vaccination does not seem to be urgent in the Netherlands. Therefore we advise studying the safety in 12-year-old girls first while at the same time waiting for the longer follow-up results of ongoing trials.

Objective: Comparison of the indicators of effectiveness and efficiency of the Dutch national cervical cancerscreening programme in 2003 and 1994, the last year before implementation of important changes in the medical and organisational guidelines., Design: Descriptive., Method: Data on all Pap smears made in 1994 and 2003 were retrieved from the Pathologic Anatomical National Automated Archive (PALGA), together with the matching cytological and histological follow-up until April 2004. In order to calculate the 5-year coverage, the number of women that had had a smear taken was placed in the numerator and divided by the number of women that had been invited for the screening programme during those 5 years., Results: The 5-year coverage in the age range 30-64 years increased from 69 in 1994 to 77% in 2003. The percentage of smears resulting in a recommendation for a repeat smear decreased from 10 to 2. The percentage of timely compliance with recommendations for a repeat smear increased from 47 to 86, while that of smears with an immediate referral recommendation remained the same (about go). There was a sharp decrease in screening outside of the target-age range and screening with too short an interval. As a consequence, despite the higher coverage, the total number of smears decreased., Conclusion: The changes in the Dutch cervical cancerscreening programme in 1996 with regard to participation, the number of and compliance with recommendations for repeat smears, and screening activity outside of the target group were accompanied by significant improvements in agreement with the goals of the revision. The potential consequences for the effectiveness of the screening programme (reduction of cervical cancer mortality) will become apparent in the years to come.

The human papillomavirus test (HPV) test could improve the (cost-) effectiveness of cervical screening by selecting women with a very low risk for cervical cancer during a long period. An analysis of a longitudinal study suggests that women with a negative Pap smear and a negative HPV test have a strongly reduced risk of developing cervical abnormalities in the years following the test, and that HPV testing lengthens the detectable stage by 2-5 years, compared to Pap smear detection alone.

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.

Objective: To determine whether the 1996 implementation of new guidelines for the classification and management of cervical smears in the Dutch population screening programme for cervical cancer (i.e. inflammatory symptoms are no longer classified as moderate dysplasia and women with two smears with moderate dysplasia are referred directly to the gynaecologist) was followed by a reduction in both the number of women with repeat smears and the length of follow-up., Methods: The results of all smears of women aged 35-54 years from 1990 onwards, were retrieved from the Dutch Network and National Database for Pathology (PALGA). The percentage of smears with moderate dysplasia was analysed with respect to time. The percentage of women with a histological examination during the follow-up phase of the population screening programme (1990 and 1991) was compared with that for the new screening programme (1996)., Results: Following the implementation of the new guidelines, the percentage of smears with moderate dysplasia was reduced from 10% to 2%. The percentage of women with a histological examination during the follow up of two smears with moderate dysplasia remained the same. The new recommendations for additional smears were not followed: for 28% no repeat smear was available after 2.25 years versus 10% in 1992. There were indications that the referral of women with two cases of moderate dysplasia to a gynaecologist was not strictly adhered to either. Since the introduction of the new guidelines, the estimated percentage of women that should be referred to the gynaecologist following smears with moderate dysplasia has not changed., Conclusion: The new recommendations have lead to fewer smears being classified as moderate dysplasia. The long-term effects, such as a reduction in the length of the follow-up period, can only be analysed in a few years time.

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.