Population-based screening programmes for cervical cancer are expanding in Europe

Population-based cervical cancer screening programmes are emerging in many Member States of the European Union. In spite of this positive development, which has the potential to decrease the current burden of cervical cancer, a special issue of the European Journal of Cancer [1] highlights the need to improve the coverage and quality of cervical cancer screening. There are 34,500 new cases of cervical cancer diagnosed in the EU annually and 16,000 deaths.
The special issue of the journal provides an update of cervical cancer screening programmes in the EU against a backdrop of change, including the development and evaluation of new screening techniques and the expansion of the EU.
The co-Editors of the issue, Dr Guglielmo Ronco and Dr Ahti Anttila, stress that cervical screening is a complex process which requires a number of coordinated steps. For the first time, systematic data on the performance of cervical screening programmes in EU countries has been collated, utilizing 15 national or regional screening registers designed for implementation, evaluation and monitoring of the programmes. Large differences in the performance of cervical screening programmes were observed [2]. In particular, there was strong variation in the interpretation of cytology between countries. For example, women with HSIL represented less than 10% of all abnormal cytology in some countries versus more than 25% in other countries.
The referral of women with an abnormal result for either a further pap smear or a colposcopy differed between countries, depending on the management protocol in place. Follow up after an abnormal pap smear result is crucial to the success of all screening programmes but low attendance for recommended colposcopies was observed in some eastern European countries. [2]
There is already a contrast in mortality from cervical cancer between the ‘old’ and ‘new’ member countries of the EU [3]. If effective screening programmes are not introduced, this seems likely to increase further as research shows that mortality rates have already decreased markedly in western European countries, whilst in eastern European countries and the Baltic states mortality rates are decreasing more slowly (Czech Republic, Poland), remaining constant (Estonia, Slovakia) or increasing (Bulgaria, Latvia, Lithuania, Romania) [3].
An optimal screening programme for cervical cancer, based on conventional cytological screening tests and conventional treatments for pre-cancer lesions can decrease cervical cancer burden by approximately 80% [4]. Dr Antilla comments, “The current incidence and death rates from cervical cancer could be reduced much further, even in countries with long-lasting spontaneous screening but without well established screening programmes, where the numbers of cervical cancer cases and deaths from the disease have been halved”
In many European countries the proportion of women within the target population who have been screened for cervical cancer remains low [5]. Screening programmes are not yet available to all women at risk from cervical cancer. However, countries with screening programmes have been able to provide women with regular screening within the recommended intervals [5].
The differences between screening programmes have an important impact on their effectiveness. Those programmes which have been running for a longer period of time are generally of higher quality, probably due to monitoring, feedback and quality assurance over a number of years [2]. A number of the programmes running in eastern and central European countries, which have only just been established, struggle to maintain the same standards.
The co-Editors of the special issue of the European Journal of Cancer stress the importance of reporting data from cervical screening programmes in the EU to improve quality. Dr Ronco explains: “There is a need to standardize the cytological and histological classifications for cervical cancer screening to improve the interpretation of pap smear results. It is also essential to improve the data registration systems used across the EU, and to produce and compare these on a regular basis.”
New screening methods for cervical cancer are emerging, including HPV-based programmes. The findings of the first few studies on the validated HPV screening methods suggest that the overall impact on reducing incidence and deaths from cervical cancer can be greater than with the conventional cytological screening currently used by many European countries [4,6]. However, if these new methods are not integrated properly with the organized screening programmes already in existence, they can add greatly to adverse effects and costs, according to Dr Ronco and Dr Anttila. They also warn that, in the absence of systematic population-based implementation and coverage, no relevant impact at a population level can yet be obtained.

[1] European Journal of Cancer, volume 45, issue 16 (October 2009). “Cervical cancer screening in the European Union.”
[2] Ronco G, van Ballegooijen M, Becker N, et al. Process performance of cervical cancer screening programmes in Europe. Eur J Cancer 2009; 45 (16): 2659 – 2670.
[3] Arbyn M, Raifu AO, Weiderpass E. Trends of cervical cancer mortality in the member states of the European Union. Eur J Cancer 2009; 45 (16): 2640 – 2648.
[4] Ronco G, Antilla A. Cervical cancer screening in Europe – changes over the last 9 years. Eur J Cancer (2009) 2629 – 2631.
[5] Antilla A, von Karsa L, Aasmaa A, et al. Cervical cancer screening policies and coverage in Europe. Eur J Cancer 2009; 45 (16): 2649 – 2658.
[6] Lynge E, Antilla A, Arbyn M, et al. What’s next? Perspectives and future needs of cervical cancer screening in Europe in the era of molecular testing and vaccination. Eur J
Cancer 2009; 45 (16): 2714 – 2721.

PDFs of the papers in the special issue can be accessed by contacting Elsevier’s Newsroom:
http://www.sciencedirect.com/science/journal/09598049

Contact: Ahti Anttila (Ahti.Anttila@cancer.fi)