Cervical Cancer Screening and Human Papillomavirus (HPV ... - KCE

iv Cervical Cancer Screening and HPV KCE reports vol.38C -
Primary screening
The sensitivity and specificity of HC2 for CIN2+ in six studies conducted in Europe and
North-America was 97.9% (95% CI: 95.9-99.9%) and 91.3% (95%: 89.5-93.1%). The
sensitivity and specificity of the combination of the HC2 assay and cytology, considering
ASCUS as cut-off for positivity, for detecting CIN2+, pooled from the 6 North-
American and European studies, was 99.2% (95% CI: 97.4-100%) and 87.3% (84.2-90.4%)
respectively. Overall, 14.5% (95% CI: 11.0-18.1%) of screened women showed a
positive result for at least one test. The specificity of HPV screening is higher if
restricted to women older than 30-35 yrs of age. With regard to PCR, the use of
different primers and detection of amplified sequences, do not allow to generalize
conclusions obtained in a particular trial.
Further research is needed to define longitudinal performance indicators. Ongoing
randomized trials compare HPV screening versus a combined HPV and cytology
screening versus cytology-based screening. Longitudinal data will be published in 2006-
2008. Based on the results of these large trials guidance on cervical cancer screening
may then have to be revised.
INTERNATIONAL SITUATION
In most European countries, cervical cancer screening started as an opportunistic
activity, performed on the initiative of women or doctors. This opportunistic screening
activity is still predominant in Europe. Cervical cancer screening often was offered in
the context of visits for birth control, so that the target group was younger women,
leaving older women unscreened.
Well-organized screening programmes have a greater impact than opportunistic
screening because they have the potential to achieve greater participation and this can
improve equity of access and the likelihood of reaching women at higher risk.
Moreover organised screening may facilitate the implementation and monitoring of
quality assurance measures.
Time trends in incidence and mortality from cervical cancer in Denmark, Finland,
Iceland, Norway, and Sweden since the early 1950s were investigated in relation to the
extent and intensity of organised screening programmes in these countries. A clear
parallelism was found between the population coverage achieved by organised screening
programmes and the decline in the incidence of and mortality from invasive cervical
cancer. In Norway, a substantial increase in coverage was observed after the start of an
organized programme in 1995, particularly in the age group 50-69 years. The incidence
of invasive cancer decreased with 22%.
In the UK a national call and recall system was set up in 1988. The impact of this
screening programme was assessed by trend analyses of incidence and cause-specific
mortality and related to screening coverage and other indicators. The coverage of the
target group in the screening programme rose from 42% in 1988 to 85% in 1994, a level
that was subsequently maintained. Coverage increased in all age groups, but particularly
in women 55 to 64 years old. The screening programme resulted in a 35% fall in
incidence of invasive disease.
In conclusion, well-organised screening appears more effective than the opportunistic
activity and could lead to a more appropriate use of available resources. To maximise
the positive impacts and minimise potential adverse effects, it is recommended that
screening should be offered in organised settings (the Commission of the European
Communities, 2003/0093; the Council of the European Union, 2003/87/EC).
The setup of a screening register is of great importance to achieve the objectives of the
programme. It should contain information on participation in screening, the screen test
results, the subsequent management of screen-positive women (compliance and results)
and it should be linked to the cancer register and the population register.