An overview of cervical cancer epidemiology and prevention in the Baltic States.

AIMS: To inform future Baltic States-specific policy analyses, we aimed to provide an overview of cervical cancer epidemiology and existing prevention efforts in Estonia, Latvia and Lithuania. METHODS: A structured desk review: we compiled and summarized data on current prevention strategies, population demography and epidemiology (high risk human papillomavirus (HPV) prevalence and cervical cancer incidence and mortality over time) for each Baltic State by reviewing published literature and official guidelines, performing registry-based analyses using secondary data and having discussions with experts in each country. RESULTS: We observed important similarities in the three Baltic States: high burden of the disease (high incidence and mortality of cervical cancer, changes in TNM (Classification of Malignant Tumors) stage distribution towards later stage at diagnosis), high burden of high-risk HPV in general population and suboptimal implementation of the preventive strategies as low screening and HPV vaccination coverage. CONCLUSIONS: Cervical cancer remains a substantial health problem in the region and the efforts in addressing barriers by implementing a four-step plan for elimination cervical cancer in Europe should be made. This goal is achievable through evidence-based steps in four key areas: vaccination, screening, treatment, and public awareness.

Excess mortality associated with the COVID-19 pandemic in Latvia: a population-level analysis of all-cause and noncommunicable disease deaths in 2020.

BACKGROUND: Age-standardised noncommunicable disease (NCD) mortality and the proportion of the elderly population in Latvia are high, while public health and health care systems are underresourced. The emerging COVID-19 pandemic raised concerns about its detrimental impact on all-cause and noncommunicable disease mortality in Latvia. We estimated the timing and number of excess all-cause and cause-specific deaths in 2020 in Latvia due to COVID-19 and selected noncommunicable diseases. METHODS: A time series analysis of all-cause and cause-specific weekly mortality from COVID-19, circulatory diseases, malignant neoplasms, diabetes mellitus, and chronic lower respiratory diseases from the National Causes of Death Database from 2015 to 2020 was used by applying generalised additive modelling (GAM) and joinpoint regression analysis. RESULTS: Between weeks 14 and 52 (from 1 April to 29 December) of 2020, a total of 3111 excess deaths (95% PI 1339 - 4832) were estimated in Latvia, resulting in 163.77 excess deaths per 100 000. Since September 30, with the outbreak of the second COVID-19 wave, 55% of all excess deaths have occurred. Altogether, COVID-19-related deaths accounted for only 28% of the estimated all-cause excess deaths. A significant increase in excess mortality was estimated for circulatory diseases (68.91 excess deaths per 100 000). Ischemic heart disease and cerebrovascular disease were listed as the underlying cause in almost 60% of COVID-19-contributing deaths. CONCLUSIONS: All-cause mortality and mortality from circulatory diseases significantly increased in Latvia during the first pandemic year. All-cause excess mortality substantially exceeded reported COVID-19-related deaths, implying COVID-19-related mortality during was significantly underestimated. Increasing mortality from circulatory diseases suggests a negative cumulative effect of COVID-19 exposure and reduced access to healthcare services for NCD patients.

Post-reproductive aged women: a lost generation in the cervical cancer screening programme.

OBJECTIVES: The aims of the study were to find out why some post-reproductive aged women did not participate in the organised cervical cancer screening programme in Latvia and to clarify factors that would motivate them to take part. METHODS: A cross-sectional study was carried out between January and July 2017 among female patients in three general practitioner (GP) practices. GP practice nurses used the Latvian national health service database to identify women aged 25-70 who had not participated in the organised programme for the last 3 years. Participants were asked to complete a specially developed questionnaire. The results were then compared between three age groups: 25-34, 35-49 and 50-70 years. RESULTS: Included in the study were 523 out of 992 women who had not attended screening; 41% were in the age group 50-70 years. Post-reproductive aged women statistically significantly more often did not take part in the programme because of lack of time (26.4%), too great a distance to the gynaecology screening clinic (10.4%), lengthy appointment waiting time (8.5%) and a belief that a smear test was unnecessary for them (8.5%); 32.1% of women in this age group indicated that if the cervical screen could be carried out by their GP it would facilitate their participation in the programme. CONCLUSION: Post-reproductive aged women in Latvia often do not attend cervical cancer screening. Analysis of personal and organisational barriers confirmed that the involvement of GPs would encourage older women to participate in the organised screening programme.

Pre-existing diabetes mellitus and all-cause mortality in cancer patients: a register-based study in Latvia.

BACKGROUND: Most studies from high income countries consistently report that preexisting diabetes reduces overall survival of cancer patients. We examined this association in a retrospective cohort study using two nation-wide population-based data sets in Latvia. MATERIAL AND METHODS: The Cancer Register, linked with the Diabetes Register and Causes of Death Database, was the first data source used to select 22,936 men and 25,338 women with cancer diagnosed from 2009 to 2013. The follow-up period ended on 28 February 2015. The National Health Service data served as a second data source, which was used to select 10,130 men and 13,236 women with cancer as the main diagnosis, who were discharged from oncology hospitals from 2009 to 2012. Prescriptions of reimbursed antidiabetic medications indicated prior diabetes status. The follow-up period started at the date of discharge and ended on 31 December 2013. A Cox proportional hazards model was used to assess association between preexisting diabetes and all-cause mortality, adjusted for age. RESULTS: Men with preexisting diabetes had better overall short-term survival: the age-adjusted hazard ratios (95% CI) were 0.86 (0.79-0.93) for the first year and 0.89 (0.80-0.98) for the first two years after cancer diagnosis according to the disease register and health service data, respectively. After three full follow-up years, their relative mortality increased, with an age-adjusted hazard ratio of 1.60 (1.28-1.99). Among women, preexisting diabetes was associated with slightly higher all-cause mortality during the entire follow-up period, with age-adjusted hazard ratios of 1.17 (1.10-1.24) for the disease register data and 1.11 (1.02-1.21) for the health service data. CONCLUSION: Interestingly, we found better overall survival of diabetic men during the first years after cancer diagnosis. We hypothesize that access to health services may be advantageous to diabetic patients who are in close contact with the healthcare system.

Cervical Cancer in the Baltic States: Can Intelligent and Personalized Cancer Screening Change the Situation?

The three Baltic States (Estonia, Latvia, and Lithuania) are among the European Union countries with the highest incidence and mortality rates for cervical cancer. In order to tackle this public health challenge, there is an urgent need to implement more advanced and effective methods in cervical cancer prevention in Baltic countries. Nationwide cervical cancer screening programs in the Baltic States commenced in 2004-2009. While the organized screening programs in these countries differ in some relevant details (target age groups, screening interval), the underlying principles and problems, barriers are universal. However, the outcomes of present screening programs are unsatisfactory. In addition, universal screening programs are extremely costly. There is a potential need for more intelligent and personalized cervical cancer screening program. In 2019 the project "Towards elimination of cervical cancer: intelligent and personalized solutions for cancer screening" (2020-2023) was developed with the main objective - to develop improved and personalized cancer screening methods within a sustainable health care system. It is expected, that more sophisticated cervical cancer screening model will be implemented in Estonia, Latvia, and Lithuania, and will have a positive impact to epidemiology of cervical cancer and public health in general.

Renal cell carcinoma trends in Latvia: incidence, mortality, and survival rates. Population-based study.

INTRODUCTION: Baltic States including Latvia are reported as having one of the highest renal cell carcinoma (RCC) incidence and mortality rates in the world. However, data are often presented without stage-specific stratification, making assessment of the overall RCC diagnosis and survival trends challenging. MATERIAL AND METHODS: We collected data on all newly diagnosed RCC patients from the national population-based cancer registry between 1997 and 2016. We analyzed RCC incidence, mortality and survival trends using Joinpoint analysis. Kaplan-Meier analysis was performed for 5- and 10-year cancer specific survival rate calculations. RESULTS: There were a total of 7893 patients with newly diagnosed RCC. The age standardized (AS) incidence rate (per 100,000) increased slightly from 8.9 in 1997 to 9.8 in 2016. There were no specific changes in the incidence rate trend. Detection of early stage RCC increased by 5.4% annually. The AS mortality rates (per 100,000) decreased from 4.9 in 1997 to 3.9 in 2016, however, it did not reach a statistically significant change. The mortality rates decreased significantly in females and in the age group of 60-69 years. The 5-year cancer specific survival (CSS) rate increased from 55.1% in 1997-2001 to 66.6% in years 2007-2011. The 10-year CSS rate increased from 49.1% in 1997-2001 to 56.5% in years 2002-2006. CONCLUSIONS: During the study period, RCC incidence rates increased and overall mortality rates did not change. Similar to the rest of the world, the incidence of RCC diagnosed at an earlier stage increased and 5- and 10-year survival rates improved.

Professionals' role in implementing a cervical cancer screening program.

The objectives of this study were to investigate the awareness, motivation, and readiness of medical staff to take part in a cervical cancer screening program (CSP), with the ultimate aim of increasing the response rate to invitation letters and improving CSP effectiveness and coverage. Certified gynecologists (GYNs) and general practitioners (GPs) practicing in the national and private healthcare systems in Latvia were given specially designed multiple-choice questionnaires. Of 213 questionnaires distributed to GYNs, 74% were completed (32% response rate of all 486 GYNs in Latvia). GPs were sent 933 questionnaires, 24% were returned (15% response rate of all 1,455 GPs in Latvia). GPs registered for 10 years or more knew significantly less about prevention and screening for cervical cancer compared to GYNs registered for the same amount of time (p = 0.05). This finding was not seen among the GYNs (p = 0.782). In the entire study group, the average score for correct answers was 5.97 (SD 2.602). Knowledge in the GP group was significantly lower (5.03, SD 2.243) than in the GYN group (7.22, SD 2.527, p < 0.001). Irrespective of specialization and place of work, knowledge was evaluated as poorer with an increase in age (RR = 0.950; p < 0.001). The knowledge, awareness, and perception of GYNs regarding cervical cancer prevention and screening in Latvia is sufficient but not good, and that of GPs is poor. Doctors would like to learn more about preventing cervical cancer.

Interobserver variation in assessment of gastric premalignant lesions: higher agreement for intestinal metaplasia than for atrophy.

BACKGROUND: Either atrophy or intestinal metaplasia of the gastric mucosa are considered premalignant lesions. The new operative link for gastritis assessment staging system is based on the detection of atrophy, and the operative link for assessment of intestinal metaplasia staging system is based on the detection of intestinal metaplasia. Good interobserver agreement is necessary for identification of any premalignant condition. AIMS: The aim of this study was to compare the agreement between findings of gastric atrophy and intestinal metaplasia by expert and general pathologists and to analyze the possible reasons behind any possible disagreement. METHODS: Patients with dyspeptic symptoms, aged 55 years and above, without previous Helicobacter pylori eradication were enrolled and analyzed according to the updated Sydney Classification by two expert pathologists and an experienced general pathologist; the results were compared with the consensus driven by the two experts. RESULTS: Gastric biopsy specimens from 121 patients (91 women) were included in the analysis; the mean age of the patients was 67.4 years. H. pylori infection was present in 61.2% of patients. The level of agreement between the general pathologist and the two experts (κ-value) was 0.12, 0.46, and 0.87, respectively, for detecting atrophy in the corpus; 0.77, 0.77, and 0.65, respectively, for detecting intestinal metaplasia in the corpus; 0.06, 0.51, and 0.54, respectively, for detecting atrophy in the antrum; and 0.69, 0.85, and 0.79, respectively, for detecting metaplasia in the antrum. CONCLUSION: The agreement was substantially higher for intestinal metaplasia than for atrophy. This could result in discrepancies when the operative link for gastritis assessment and operative link for assessment of intestinal metaplasia staging systems are applied and can be caused by differences in the criteria used to define atrophy.

Changing patterns of serological testing for celiac disease in Latvia.

BACKGROUND AND AIMS: A number of recent guidelines have discouraged the use of the old anti-gliadin tests for the detection of celiac disease; tissue transglutaminase IgA (tTGA) and anti-endomysial (EMA) tests are recommended instead. Our aim was to evaluate how the current recommendations have been applied in real practice. The secondary aim was to evaluate the positivity rates provided by different test types. METHODS: We analyzed the number of celiac disease tests [anti-gliadin IgA (AGA), anti-gliadin IgG (AGG), tTGA and EMA] performed by the largest laboratory in Latvia. The analysis was performed on a yearly basis for the period between 2004 and 2009. Additionally, we analyzed the percentage of the positive test results for each of the tests. RESULTS: The number of patients being tested for celiac disease constantly increased, with the average annual growth of 16.1%; this trend was similar both in children and in adults. The majority of patients (62.6%) were tested with anti-gliadin tests only; 27.7% were tested with either tTGA or EMA, while 9.7% were tested by a combination of the above groups. There was a substantial difference in the positivity rates of the different tests from 0.94% for EMA to 21.8% for AGG. Substantial differences were also present between various manufacturers' products. CONCLUSION: The current guidelines and the published evidence on the proper use of serological tests for celiac disease have been slow to be applied in clinical practice; more intensive education campaigns and change in reimbursement systems could improve the situation. Nevertheless, more clinicians in Latvia are checking patients for celiac disease; this suggests an overall increased awareness.