Search

Cervical cancer screening coverage is a key monitoring indicator of the WHO cervical cancer elimination plan. We present global, regional, and national cervical screening coverage estimates against the backdrop of the 70% coverage target set by WHO.In this review and synthetic analysis, we searched scientific literature, government websites, and official documentation to identify official national recommendations and coverage data for cervical cancer screening for the 194 WHO member states and eight associated countries and territories published from database inception until Oct 30, 2020, supplemented with a formal WHO country consultation from Nov 27, 2020, to Feb 12, 2021. We extracted data on the year of introduction of recommendations, the existence of individual invitation to participate, financing of screening tests, primary screening and triage tests used, recommended ages and screening intervals, use of self-sampling, and use of screen-and-treat approaches. We also collected coverage data, either administrative or survey-based, as disaggregated as possible by age and for any available screening interval. According to data completeness and representativeness, different statistical models were developed to produce national age-specific coverages by screening interval, which were transformed into single-age datapoints. Missing data were imputed. Estimates were applied to the 2019 population and aggregated by region and income level.We identified recommendations for cervical screening in 139 (69%) of 202 countries and territories. Cytology was the primary screening test in 109 (78%) of 139 countries. 48 (35%) of 139 countries recommended primary HPV-based screening. Visual inspection with acetic acid was the most recommended test in resource-limited settings. Estimated worldwide coverage in women aged 30-49 years in 2019 was 15% in the previous year, 28% in the previous 3 years, and 32% in the previous 5 years, and 36% ever in lifetime. An estimated 1·6 billion (67%) of 2·3 billion women aged 20-70 years, including 662 million (64%) of 1·0 billion women aged 30-49 years, had never been screened for cervical cancer. 133 million (84%) of 158 million women aged 30-49 years living in high-income countries had been screened ever in lifetime, compared with 194 million (48%) of 404 million women in upper-middle-income countries, 34 million (9%) of 397 million women in lower-middle-income countries, and 8 million (11%) of 74 million in low-income countries.Two in three women aged 30-49 years have never been screened for cervical cancer. Roll-out of screening is very low in low-income and middle-income countries, where the burden of disease is highest. The priority of the WHO elimination campaign should be to increase both screening coverage and treatment of detected lesions; however, expanding the efforts of surveillance systems in both coverage and quality control are major challenges to achieving the WHO elimination target.Instituto de Salud Carlos III, European Regional Development Fund, Secretariat for Universities and Research of the Department of Business and Knowledge of the Government of Catalonia, and Horizon 2020.For the French, Spanish translations of the abstract see Supplementary Materials section.

ObjectiveTo evaluate the 9-year incidence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and cumulative adherence to perform a next test in a cohort of women aged 40+ years with no cervical screening cytology within a window of 5 years (underscreened women), after baseline cervical cytology and HPV tests.MethodsIn Catalonia, Spain, co-testing with cytology and HPV test has been recommended in the Public Health system since 2006 for underscreened women. In 2007, 1,594 women with underscreened criteria were identified and followed through medical records form Pathological Department. 9-year cumulative incidence of histologically confirmed CIN2+ and cumulative adherence to perform a next test were estimated using Kaplan-Meier statistics.ResultsFollow-up was available for 1,009 women (63.3%) resulting in 23 women with. CIN2+ (2.3%). Of them, 4 women (17%) had both tests negative at baseline (3CIN2 and 1CIN3) with cumulative incidence of CIN2+ of 0.4% (95% CI: 0.1-1.4) at 5-years and 1.3% (95% CI: 0.4-3.7) at 9-years. During the first year, the prevalence among women with both tests positive was 27.0% (95% CI: 13.0-50.6) for CIN2+. Lost to follow-up was higher among women with both tests negative compared to those with both positive tests (38.7% vs 4.2%, p-value ConclusionsHPV detection shows a high longitudinal predictive value at 9-year to identify women at risk to develop CIN2+. The data validate a safe extension of the 3-year screening intervals (current screening interval) to 5-year intervals in underscreened women that had negative HPV result at baseline. It is necessary to establish mechanisms to ensure screening participation and adequate follow-up for these women.

ObjectiveIn stroke survivors, atrial fibrillation (AF) is typically evaluated solely by short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring or insertable cardiac monitors require substantial resources. Chest and thumb ECG could provide an alternative means of AF detection, which in turn could allow prompt anticoagulation to prevent recurrent stroke. The objective of this study was to assess the yield of newly diagnosed AF during 28 days of chest and thumb ECG monitoring two times per day in cryptogenic stroke.MethodsThis study, Transient ECG Assessment in Stroke Evaluation, included patients who had a stroke from Region Gävleborg, Sweden, between 2017 and 2019. Patients with a recent ischaemic stroke without documented AF (or other reasons for anticoagulation) before or during ECG evaluation in the stroke unit were evaluated using the Coala Heart Monitor connected to a smartphone application for remote monitoring.ResultsThe prespecified number of 100 patients (mean age 67.6±10.8 years; 60% men) was analysed. In nine patients (9%, number needed to screen 11) AF but no other significant atrial arrhythmias (>30 s) was diagnosed. The mean CHA2DS2-VASc score was similar among patients with AF and no AF (4.9±1.1 vs 4.3±1.3; p=0.224) and patients with AF were older (74.3±9.0 vs 66.9±10.8; p=0.049). Patients performed on average 90.1%±15.0% of scheduled transmissions.ConclusionIn evaluation of cryptogenic stroke, 9% of patients had AF detected using chest and thumb ECG two times per day during 1 month. In many stroke survivors, this is a feasible approach and they will be potentially protected from recurrent stroke by anticoagulation treatment.Trial registration numberNCT03301662.

Extensive multiple-age cohort human papillomavirus (HPV) vaccination has proved to be highly effective. We aimed to determine the 8-year population impact of a female single-age cohort HPV vaccination programme on the incidence of anogenital warts (AGW). In 2008, Catalonia initiated a school-based quadrivalent HPV vaccination programme targeting 11-year-old girls, achieving coverage over 80%. Data on diagnoses of AGW and genital herpes were obtained from a population-based database of electronic health records covering 74% of the population. The annual incidence rates from 2009 to 2016 were calculated, stratified by age and sex using Joinpoint regression to estimate trends and annual percentage changes (APC). Among women aged 16–19 years, the AGW incidence decreased by 61% from 2012 to 2016 (APC −19.4%; 95% CI: −30.0 to −7.3). In contrast, the incidence of genital herpes in same-aged women increased throughout the study period (APC 11.1%; 95% CI: 7.2–15.2). Among men aged 20–22 years, the increasing incidence of AGW shifted to a downward trend in 2013 (APC 2009–2013: 17.0%; 95% CI: 8.2–26.5; and APC 2013–2016: −4.5%; 95% CI: −14.6 to 6.9). A similar pattern was observed among men aged 23–25 years (APC 2009–2014: 16.0%; 95% CI: 12.0–20.2; and APC 2014–2016: −6.0%; 95% CI: −18.4 to 8.3). In contrast to AGW, among men aged 20–25 years, the incidence of genital herpes increased over this period. Our study strongly suggests that a single-cohort HPV vaccination strategy with high vaccine uptake not only provides direct benefit in the vaccinated cohorts but also extends protection through a herd effect to unvaccinated men.

Analysis of the cervical cancer screening activity in the National Health System of Catalonia has identified a cytological coverage at 3 years of 40.8%, an interval of 2.4 years between Pap smears and a loss to follow-up of 50% at 3 years in women aged 25-65 years old. The introduction of human papillomavirus testing in the management of women with cytological results of atypical squamous cell of undetermined significance and as an adjunct to cytology in women with a history of inadequate screening has facilitated the management and detection of women at risk of developing cervical intraepithelial neoplasia grade 2 or worse (CIN2 + ). Human papillomavirus testing has demonstrated high sensitivity and specificity at 3 years in the detection of CIN2 + and was substantially superior to cytology. Furthermore, it had good inter-laboratory reproducibility and was easy to perform in routine situations. The use of uniform protocols and the extensive availability of software tools have allowed comprehensive and reliable assessment across Catalonia. The protocol has been complemented with educational interventions for healthcare professionals and regular monitoring of all activities. We conclude that the introduction of organized screening programs and human papillomavirus testing among women older than 30 years can greatly enhance efforts for the secondary prevention of CC in Catalonia.

To evaluate prospectively the association between serological markers of selected infections, including HPV, and risk of developing cervical cancer (CC) and pre-cancer, we performed a nested case-c ...

A total of 308,036 women were selected from the European Prospective Investigation into Cancer and Nutrition (EPIC) to evaluate the association between tobacco smoking and the risk of cervical intr ...

This manuscript provides the available data on the burden of human papillomavirus (HPV) infections and HPV-related diseases in Israel. The incidence of cervical intraepithelial neoplasia grade 3 (CIN3) among Jewish women was 17.4 per 100,000 in 2007, showing an increase since 1997. The incidence of cervical cancer was 5.3 per 100,000 Israeli Jewish women and 2.3 per 100,000 Israeli non-Jewish women in 2007. This rate is relatively low compared to other developed countries, and could be explained by cultural and religious factors such as male circumcision or sexual behavior. Mortality rates were around 1.5 per 100,000 Israeli women in 2007. Incidences of other anogenital, oral cavity, and pharynx cancers are very low, below 1.0 per 100.000 Israeli women and men. Information is scarce on HPV prevalence and HPV type distribution among women with cervical cancer. HPV types 16 and 18 were the two most common types in both preneoplastic lesions and cervical cancer, representing 60% of total invasive cases. Data on genital warts show an incidence rate of 239 per 100,000 men and 185 per 100,000 women, similar to that found in other Western countries. Despite these low incidences, it is important to improve the information on the overall burden of HPV-related morbidity and on the HPV prevalence to evaluate an organized cervical cancer screening program and the introduction of the HPV vaccine in the national school-based vaccine program. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in Israel" Vaccine Volume 31, Supplement 8, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Objectives The AFRODITA study was designed to describe patterns relating to the number of lifetime sexual partners (SP) and age at first sexual intercourse (AFSI) by geographic region in a representative sample of Spanish women. Study design A representative sample of the female Spanish population was obtained using the Access Panel Technique. Postal questionnaires were sent to 11,086 women aged 18–70 years. Data were collected on AFSI, number of sexual partners, contraceptive methods, cervical cancer screening and socio-demographic characteristics. Results The average AFSI was 20.9 years. AFSI below the age of 19 years was reported by 30.8% of the women. Among sexually active women, 70.6% reported being monogamous and 6.4% reported ≥5 lifetime sexual partners. Younger age at interview was strongly related to earlier AFSI and to higher number of lifetime sexual partners. Women younger than 25 were 39 times more likely to have an AFSI before age 18 than women over age 55. The percentage of women aged less than 25 reporting two or more sexual partners was four times higher than that of women 56 and older. In the multivariate analysis, having two or more sexual partners was independently associated with young age, early AFSI, having ever used oral contraceptives, living in an urban area, having had a screening Pap test in the last 3 years, having a sexually transmitted infection and nuliparity. Conclusions This study confirms important changes in the sexual behaviour of Spanish women. Younger cohorts show a younger age at sexual initiation and higher number of sexual partners. These are key factors that may induce changes in the human papillomavirus (HPV) prevalence and the cervical cancer incidence in Spain.

h Abstract Objective. To quantify the coverage and monitor the factors associated with opportunistic cervical cytological screening in Spain. Materials and Methods. Population-based survey of selected women through the Access Panel technique representative of the general population. A total of 6,852 women (60%) replied to the questionnaire; 981 (14.3%) were excluded from the analysis because they did not meet the screening criteria. Data were adjusted for regions, age group, socioeconomic level (SEL), and municipality size. Moreover, information was collected on preventive gynecological revisions received. Categorical variables were evaluated through the W 2 test of heterogeneity or through a liner test for trend. Multivariate prevalence odds ratios were used to identify statistically significant determinants of screening using logistic regression modeling. Results. The percentage of women 18 to 65 years old with a Pap smear within the last 3 years was 75.6%. Insufficient coverage was observed in women older than 55 years (66%), who live in rural areas (66%), with lower SEL (65%), and in some regions (61%Y66%). The factors positively associated with screening were age 26 to 55 years, certain regions, higher SEL, larger municipality size, ever being pregnant, early age at first sexual intercourse, knowledge about cervical cancer and human papillomavirus, and, very strongly, ever use of contraceptive methods. An overuse of cytology can be assumed, as a result of opportunistic screening. Conclusions. In Spain, the coverage of cytological screening reached 75% of the population, but with inefficiencies in some aspects. To rationalize its use, the Spanish consensus screening protocol must be followed. h

The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by the Health Research Fund (FIS) of the Spanish Ministry of Health (Exp P10710130) In addition to HPV, high parity and hormonal contraceptives have been associated with cervical cancer (CC). However, most of the evidence comes from retrospective case-control studies. The aim of this study is to prospectively evaluate associations between hormonal factors and risk of developing cervical intraepithelial neoplasia grade 3 (CIN3)/carcinoma in situ (CIS) and invasive cervical cancer (ICC). We followed a cohort of 308,036 women recruited in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study. At enrollment, participants completed a questionnaire and provided serum. After a 9-year median follow-up, 261 ICC and 804 CIN3/CIS cases were reported. In a nested case-control study, the sera from 609 cases and 1,218 matched controls were tested for L1 antibodies against HPV types 11,16,18,31,33,35,45,52,58, and antibodies against Chlamydia trachomatis and Human herpesvirus 2. Multivariate analyses were performed to estimate hazard ratios (HR), odds ratios (OR) and corresponding 95% confidence intervals (CI). The cohort analysis showed that number of full-term pregnancies was positively associated with CIN3/CIS risk (p-trend = 0.03). Duration of oral contraceptives use was associated with a significantly increased risk of both CIN3/CIS and ICC (HR = 1.6 and HR = 1.8 respectively for ≥15 years versus never use). Ever use of menopausal hormone therapy was associated with a reduced risk of ICC (HR = 0.5, 95%CI: 0.4-0.8). A non-significant reduced risk of ICC with ever use of intrauterine devices (IUD) was found in the nested case-control analysis (OR = 0.6). Analyses restricted to all cases and HPV seropositive controls yielded similar results, revealing a significant inverse association with IUD for combined CIN3/CIS and ICC (OR = 0.7). Even though HPV is the necessary cause of CC, our results suggest that several hormonal factors are risk factors for cervical carcinogenesis. Adherence to current cervical cancer screening guidelines should minimize the increased risk of CC associated with these hormonal risk factors.

To estimate cervical cytology coverage for the period 2008-2011 by age groups and health regions from data recorded in the medical records of women attending centers within the Catalan national health system.The data used to estimate coverage were obtained from the primary care information system. This information was anonymous and included age, center, date, and the results of cytological smears for a total of 2,292,564 women aged 15 years or more.A total of 758,690 smears were performed in 595,868 women. Among women aged 25-65 years, the estimated coverage was 32.4% of the assigned population and was 40.8% in the population attended. Geographical variation was observed, with higher coverage among health regions closer to Barcelona. Abnormal Pap smears increased slightly from 2008 to 2011 (from 3% to 3.5%, respectively, p0.001). In women with a negative first smear, the mean interval until the second smear was 2.4 years, but only 50% of women with a negative first smear in 2008 attended a second round during the study period.Cervical screening coverage in the National Health Service of Catalonia includes one in three women. Second round participation was poor. Existing computer systems in primary care centers can ensure monitoring of population-based screening programs for cervical cancer. These systems could be used to plan an organized screening program to ensure wider coverage and better follow-up.

Human papillomavirus (HPV) infection is a necessary cause of cervical cancer. The aim of this study was to estimate the prevalence of cervical HPV infection and HPV type-specific distribution among women attending cervical cancer screening in Spain during 2007 and 2008. Women aged 18-65 years were recruited according to an age-stratified sampling method. Liquid-based cervical samples were collected and analyzed for cytology, HPV detection, and genotyping. HPV genotyping was determined using the INNO-LiPA HPV Genotyping Extra Reverse Hybridization Line Probe Assay. Prevalence estimates were age-standardized using 2001 Spanish census data. The present study included 3,261 women. Age-standardized HC2-based HPV prevalence was 14.3% (95% CI, 13.1-15.5) among women aged 18-65 years, and 28.8% (26.6-31.1) among women aged 18-25 years. High-risk HPV types were detected in 12.2% (95% CI, 11.1-13.4) of HPV-tested women, representing 84.0% of HPV-positive samples. Multiple infections were present in 4.1% (95% CI, 3.4-4.8) of HPV-tested women (25.0% of HPV-positive samples). The most common high-risk HPV-types among HPV-tested women were 16 (2.9%), 52 (1.8%), 51 (1.6%), 31 (1.3%), and 66 (1.2%). HPV-type 16 was present in 16.9% of HPV-positive samples. One or more of the HPV vaccine types 6/11/16/18 were detected in 3.8% of HPV-tested women (22.1% of HPV-positive samples). Though not a true population-based survey, this study provides valuable baseline data for future assessment of the impact of current HPV vaccination programs in Spain. The high prevalence of HPV infection among young women may reflect recent changes in sexual behavior.

Udgivelsesdato: 2010-Sep-17 Some dietary factors could be involved as co-factors in cervical carcinogenesis but evidence is inconclusive. There is no data about the effect of fruits and vegetables intake (F&V) on cervical cancer from cohort studies.We examined the association between the intake of F&V and selected nutrients and the incidence of carcinoma in-situ (CIS) and invasive squamous cervical cancer (ISC) in a prospective study of 299,649 women, participating in the European Prospective Investigation Into Cancer and Nutrition (EPIC) study. Cox proportional hazard models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (95%CI).A calibration study was used to control measurement errors in the dietary questionnaire.After a mean of 9 years of follow-up, 253 ISC and 817 CIS cases were diagnosed. In the calibrated model, we observed a statistically significant inverse association of ISC with a daily increase in intake of 100g of total fruits (HR 0.83; 95%CI 0.72-0.98) and a statistically nonsignificant inverse association with a daily increase in intake of 100 g of total vegetables (HR 0.85: 95%CI 0.65-1.10). Statistically nonsignificant inverse associations were also observed for leafy vegetables, root vegetables, garlic and onions, citrus fruits, vitamin C, vitamin E, and retinol for ISC. No association was found regarding beta-carotene, vitamin D and folic acid for ISC. None of the dietary factors examined were associated with CIS. Our study suggests a possible protective role of fruit intake and other dietary factors on ISC, that need to be confirmed on a larger number of ISC cases.

The AFRODITA study was designed to describe patterns relating to the number of lifetime sexual partners (SP) and age at first sexual intercourse (AFSI) by geographic region in a representative sample of Spanish women.A representative sample of the female Spanish population was obtained using the Access Panel Technique. Postal questionnaires were sent to 11,086 women aged 18-70 years. Data were collected on AFSI, number of sexual partners, contraceptive methods, cervical cancer screening and socio-demographic characteristics.The average AFSI was 20.9 years. AFSI below the age of 19 years was reported by 30.8% of the women. Among sexually active women, 70.6% reported being monogamous and 6.4% reportedor = 5 lifetime sexual partners. Younger age at interview was strongly related to earlier AFSI and to higher number of lifetime sexual partners. Women younger than 25 were 39 times more likely to have an AFSI before age 18 than women over age 55. The percentage of women aged less than 25 reporting two or more sexual partners was four times higher than that of women 56 and older. In the multivariate analysis, having two or more sexual partners was independently associated with young age, early AFSI, having ever used oral contraceptives, living in an urban area, having had a screening Pap test in the last 3 years, having a sexually transmitted infection and nuliparity.This study confirms important changes in the sexual behaviour of Spanish women. Younger cohorts show a younger age at sexual initiation and higher number of sexual partners. These are key factors that may induce changes in the human papillomavirus (HPV) prevalence and the cervical cancer incidence in Spain.