Social determinants influencing cervical cancer diagnosis: an ecological study.

BACKGROUND: Barriers to accessing health care result in advanced cervical cancer. In Sao Paulo, Brazil, the Index of Social Responsibility (ISR) synthesizes the situation of each town concerning wealth, education, and longevity. This study aimed to evaluate in 645 municipalities the relation of the ISR with stage, age, and morphology in cervical cancer diagnosis. METHODS: An ecological study that used data from Sao Paulo, Brazil, from 2010 to 2017. The ISR was identified through government platforms and data on cancer through the Hospital Cancer Registry. The subjects were the 9,095 women aged 30 years or older. The ISR summarizes municipalities into five levels: dynamic (ISR5), unequal (ISR4), equitable (ISR3), in transition (ISR2), and vulnerable (ISR1). It was used the chi2 tests and logistic regression. RESULTS: The proportion of stage 1 increased significantly with ISR level, ranging from 24.9% in ISR1 to 30.0% in ISR5 (p = 0.040). To every increase in ISR level, the chance of a woman being diagnosed in stage I was at least 30% higher. Woman living where ISR2 had a 1.4 times higher chance of being diagnosed in stage 1 than those living in ISR1 (OR 1.40, 95% CI 1.07-1.84). Squamous tumors frequency decreased when ISR level increased (p = 0.117). A higher proportion of women under 50 years were observed when they lived in wealthier cities (ISR4 and ISR5) (42.2% vs. 44.6%, p = 0.016). CONCLUSION: The ISR was a good health indicator for understanding and predicting the social determinants in cervical cancer diagnosis. The proportion of stage I increased significantly in more favorable social conditions.

The value of the endocervical margin status in LEEP: analysis of 610 cases.

PURPOSE: To describe the results of 610 patients who underwent LEEP and evaluate factors related to a negative margin. METHODS: A retrospective study of patients treated by LEEP at a colposcopy referral service in Campinas, Brazil, 2017-2019. Patients were referred to treat high-grade squamous intraepithelial lesion or adenocarcinoma in situ suspected by cytology and colposcopy (screen-and-treat) or by biopsy. Descriptive analysis was performed by frequencies as a function of the status of the margins (negative or positive). Factors associated with margin status were assessed by regression. RESULTS: The endocervical, ectocervical or both margins were negative in 82.4%, 75.7% and 65.9%, respectively. Age, sexual debut, parity, menopause status, smoking and hormonal contraception showed no difference in the proportion of negative margins. Both margins were negative in 66.1% of patients with transformation zone type(TZ) 1, 73.1% of TZ 2, and 54.7% of TZ 3 (p = 0.015). The endocervical negative margin was obtained in 78.0% of patients submitted to excision I (loop 10 mm) and 82.5% to excision II (loop 15 mm) (p = 0.016). Having the sexual debut at 18 years or older or being submitted to an excision type II doubled the chance of negative endocervical margin (1.98;1.04-3.77 and 1.95; 1.18-3.21, respectively). CONCLUSION: The proportion of negative endocervical margin was 78% in excision I and 86% in excision II. Sexual onset and excision type II increased the chance of obtaining a negative endocervical margin.

Endocervical Margins Status in Excision for Preventing Cervical Cancer According to the Transformation Zone Type.

OBJECTIVE: The aim of this study is to assess the outcomes of 610 excision types I and II in a referral facility as a function of transformation zone (TZ) types. METHODS: This is a retrospective cohort study of women with cervical precursor lesions who underwent loop electrocautery excision procedure from 2017 to 2019 at the University of Campinas. The primary outcome was endocervical margin status, negative or positive. Other variables were excision type (I/II), TZ (1/2/3), age, menopausal status, hormonal contraceptives, smoking, and sexual debut. Tests used were chi-square or Fisher exact, Mann-Whitney, and simple and multiple logistic regression. RESULTS: The most frequent was TZ 1 (62.5%). Excision II was the most frequent: 54.1% in TZ 1, 67.2% in TZ 2, and 82.1% in TZ 3. A negative margin was observed in TZ 1, 76.0% when excision I and 86.4% when excision II ( p = .009); TZ 2, 86.4% when excision I and 88.9% when excision II ( p = .672); and TZ 3, 76.5% when excision I and 78.9% when excision II ( p = .672). Multivariate analysis revealed in TZ 1 a 2.12 (1.23-3.65) higher risk of obtaining a negative margin in excision type II. In TZ 2 and 3, none of the variables predicted the chance of a negative margin. CONCLUSIONS: The endocervical margin was negative in 3 in every 4 women who underwent loop electrocautery excision procedure, regardless of excision type. Age, menopausal status, smoking, and hormonal contraception did not predict margin status.

Race disparities in mortality by breast cancer from 2000 to 2017 in São Paulo, Brazil: a population-based retrospective study.

BACKGROUND: In Brazil, inequalities in access may interfere with cancer care. This study aimed to evaluate the influence of race on breast cancer mortality in the state of São Paulo, from 2000 to 2017, contextualizing with other causes of death. METHODS: A population-based retrospective study using mortality rates, age and race as variables. Information on deaths was collected from the Ministry of Health Information System. Only white and black categories were used. Mortality rates were age-adjusted by the standard method. For statistical analysis, linear regression was carried out. RESULTS: There were 60,940 deaths registered as breast cancer deaths, 46,365 in white and 10,588 in black women. The mortality rates for 100,000 women in 2017 were 16.46 in white and 9.57 in black women, a trend to reduction in white (p = 0.002), and to increase in black women (p = 0.010). This effect was more significant for white women (p < 0.001). The trend to reduction was consistent in all age groups in white women, and the trend to increase was observed only in the 40-49 years group in black women. For 'all-cancer causes', the trend was to a reduction in white (p = 0.031) and to increase in black women (p < 0.001). For 'ill-defined causes' and 'external causes', the trend was to reduce both races (p < 0.001). CONCLUSION: The declared race influenced mortality rates due to breast cancer in São Paulo. The divergences observed between white and black women also were evident in all cancer causes of death, which may indicate inequities in access to highly complex health care in our setting.

The impact of the Covid-19 pandemic on breast cancer early detection and screening.

The COVID-19 pandemic affects mortality and morbidity, with disruptions expected to continue for some time, with access to timely cancer-related services a concern. For breast cancer, early detection and treatment is key to improved survival and longer-term quality of life. Health services generally have been strained and in many settings with population breast mammography screening, efforts to diagnose and treat breast cancers earlier have been paused or have had reduced capacity. The resulting delays to diagnosis and treatment may lead to more intensive treatment requirements and, potentially, increased mortality. Modelled evaluations can support responses to the pandemic by estimating short- and long-term outcomes for various scenarios. Multiple calibrated and validated models exist for breast cancer screening, and some have been applied in 2020 to estimate the impact of breast screening disruptions and compare options for recovery, in a range of international settings. On behalf of the Covid and Cancer Modelling Consortium (CCGMC) Working Group 2 (Breast Cancer), we summarize and provide examples of such in a range of settings internationally, and propose priorities for future modelling exercises. International expert collaborations from the CCGMC Working Group 2 (Breast Cancer) will conduct analyses and modelling studies needed to inform key stakeholders recovery efforts in order to mitigate the impact of the pandemic on early diagnosis and treatment of breast cancer.

Cervical cancer screening program based on primary DNA-HPV testing in a Brazilian city: a cost-effectiveness study protocol.

BACKGROUND: The causal relationship between high-risk (hr) HPV infection and precancerous lesions or cervical cancer has led to the development of strategies to increase screening performance and prevent this cancer. The increased sensitivity of DNA-HPV testing compared to cervical cytology favors DNA-HPV testing as a primary screening test. Cervical cancer screening in Brazil is opportunistic, and this cancer remains a considerable health problem with a high proportion of diagnoses in advanced stages. This paper aims to describe the design and implementation of the Cervical Cancer Screening Program with primary DNA-HPV testing (CCSP-HPV) planned for Indaiatuba City (SP), Brazil; the strategies to achieve higher population coverage; and a study protocol for cost-effectiveness analyses. METHODS: The CCSP-HPV was designed based on successful guidelines that replaced cervical cytology-based screening by the DNA-HPV test performed at 5-year intervals. The screening will be performed for the female population aged 25-64 years cared for by the public health system and aim to reach 80% coverage after completing the first round. The chosen DNA-HPV test detects 14 hr-HPV types and genotypes HPV-16 and 18. All women with a negative test will be reassessed after five years. Women showing a positive test for HPV-16 and/or 18 will be referred for colposcopy. Those showing the other 12 hr-HPV types will be tested by cytology, and if any abnormality is detected, they will also be referred for colposcopy. The histopathologic evaluation will be reviewed by a pathologist panel and aided by p16 immunohistochemistry. A cost-effectiveness analysis will be performed by a Markov model comparing the cost of the new program and the screening performed by conventional cytology five years prior (2011-2016). DISCUSSION: The new screening program is considered a breakthrough for public health regarding cervical cancer, which is the third leading cause of cancer death among Brazilian women. Achieving at least 80% coverage will have the possibility to change this scenario. The proposed program will provide a modern cervical cancer screening method for women, and information about cost-effectiveness will help other similar places support the decision of implementing cervical cancer screening using the DNA-HPV test.

Performance of colorectal cancer screening in the European Union Member States: data from the second European screening report.

OBJECTIVE: To present comparative data about the performance of colorectal cancer (CRC) screening programmes in the European Union Member States (EU MSs). DESIGN: Cross-sectional study. We analysed key performance indicators-participation rate, positivity rate (PR), detection rate (DR) and positive predictive value for adenomas and CRC-based on the aggregated quantitative data collected for the second EU screening report. We derived crude and pooled (through a random effects model) estimates to describe and compare trends across different MSs/regions and screening protocols. RESULTS: Participation rate was higher in countries adopting faecal immunochemical test (FIT) (range: 22.8%-71.3%) than in those using guaiac faecal occult blood test (gFOBT) (range 4.5%-66.6%), and it showed a positive correlation (ρ=0.842, p<0.001) with participation in breast cancer screening in the same areas. Screening performance showed a large variability. Compliance with referral for colonoscopy (total colonoscopy (TC)) assessment ranged between 64% and 92%; TC completion rate ranged between 92% and 99%. PR and DR of advanced adenomas and CRC were higher in FIT, as compared with gFOBT programmes, and independent of the protocol among men, older subjects and those performing their first screening. CONCLUSIONS: The variability in the results of quality indicators across population-based screening programmes highlights the importance of continuous monitoring, as well as the need to promote quality improvement efforts, as recommended in the EU guidelines. The implementation of monitoring systems, ensuring availability of data for the entire process, together with initiatives aimed to enhance reproducibility of histology and quality of endoscopy, represent a priority in screening programmes management.

Downstaging in opportunistic breast cancer screening in Brazil: a temporal trend analysis.

BACKGROUND: Breast cancer is the most common female cancer in Brazil with an estimated 60 thousand new cases per year. Widespread use of mammography opportunistic screening has been observed in the last 20 years, including women under 50 years old. The present study aimed to analyse the trends in breast cancer stage distribution at diagnosis as a function of age in the study period. METHODS: This paper examined temporal trends of stage distribution in women with breast cancer diagnosed between 2000 and 2015 in São Paulo state, Brazil. Data from the Hospital Cancer Registry of the region were utilized. Completeness was high. The sample was described according to age, stage and date of diagnosis using absolute frequency and proportions (%). For trends, the Cochran-Armitage test was used with a 5% level of significance (P-value< 0.05). RESULTS: A total of 93,674 women were included in the analysis with a median age of 56 years old. One-third (34.4%) of the women were younger than 50 years old, and stage II was the most frequent stage (36.4%), even when analysed by age groups. Stage 0 corresponded to 7.7% (7247 women) of cases. In the study period, there was a significant trend towards an increase in Stages 0, I and IV (P < 0.01) and a trend towards a decrease in Stages IIA, IIB and IIIB (P < 0.001). Stage IIA was more prevalent until 2009, and stage I was more prevalent thereafter. The trends to increase the proportion of Stages 0 and I and to decrease the proportion of stages IIA, IIB and IIIB were significant in all age groups. CONCLUSIONS: Breast cancer cases are diagnosed mainly at early stages, and approximately one-third of cases are younger than 50 years old. Downstaging has been shown. Opportunistic screening may have supported these results. Further studies are needed to show whether these results will impact the prognosis.

Estimating the public health impact of a national guideline on cervical cancer screening: an audit study of a program in Campinas, Brazil.

BACKGROUND: A Brazilian guideline on cervical cancer screening was released in 2011. The objective was to verify changes in screening indicators around this period. METHODS: An audit study which sample was all screening tests performed by the public health system of Campinas city from 2010 to 2016. Variables were absolute tests numbers, excess tests, intervals and results, by age. For trend analysis was used Cochran-Armitage × 2 and linear regression. RESULTS: Were carried out 62,925 tests in 2010 and 43,523 tests in 2016, a tendency at a reduction (P = 0.001). Excess tests were higher than 50% over the years, with a tendency at a reduction (P < 0.001). Tests performed on women under 25 ranged from 20.2 to 15.4% in the period (P < 0.001), while in the 25-64 years age-group, it ranged from 75.1 to 80.2% (P < 0.001). In 2010 the most frequent interval was annual (47.5%) and in 2016 biennial (34.7%). There was a tendency at a reduction in the proportion of tests performed at the first time and those with an annual interval (P < 0.001), and also a tendency at an increase in tests with intervals equal to or greater than biannual (P < 0.001). We observed a tendency at a reduction in LSIL and HSIL-CIN2 results (P = 0.04 and P = 0.001, respectively), and a tendency at an increase in HSIL-CIN3 result (P = 0.02). CONCLUSION: The proportion of cervical cancer screening tests performed out of the recommendation showed a significant reduction in the period. This indicates a tendency to align cervical cancer screening in Campinas with the standards recommended.

Level of human development is associated with cervical cancer stage at diagnosis.

The objective was to describe the cervical cancer cases in Brazil by the age-group and stage at diagnosis, and to associate them with the human development index (HDI), where the women live. This was a retrospective study that used data from the Brazilian hospital-based cancer registry from 2005 to 2014. The data were accessed by 5-year age/groups and the federal units. The association between the proportion of cases at Stage I and HDI was estimated in an adjusted linear regression analysis. Among the staged cases, the proportions of cases diagnosed at FIGO Stage I, II, III and IV were 21.2%, 30.7%, 39.9% and 8.2%, respectively. The cases were diagnosed mostly in women aged 45-49 years. There was a significant increase in the proportion of Stage I cases with an increasing HDI (coefficient, 0.46; 95% confidence interval, 0.17-0.76). In conclusion, most of the cases were diagnosed at late stages. The stage at the diagnosis was associated with the human development level. Impact Statement What is already known on this subject? The stage at diagnosis varies according to the level of organisation of the cancer control programme. It is expected that in well-developed programmes there will be a shift to an early stage diagnosis. What the results of this study add? The stage at a diagnosis was associated with the human development level where the women live in Brazil, where most cases were diagnosed at the late stages. What the implications are of these findings for clinical practice and/or further research? This analysis can help with better planning strategies for cancer control. Regional strategies would improve the efficiency of cancer care interventions in countries with large socioeconomic disparities.

Status of implementation and organization of cancer screening in The European Union Member States-Summary results from the second European screening report.

The second report on the implementation status of cancer screening in European Union (EU) was published in 2017. The report described the implementation status, protocols and organization (updated till 2016) and invitation coverage (for index year 2013) of breast, cervical and colorectal cancer screening in the EU. Experts in screening programme monitoring (N = 80) from the EU Member States having access to requisite information in their respective countries provided data on breast, cervical and colorectal cancer screening through online questionnaires. Data was collected for screening performed in the framework of publicly mandated programmes only. Filled in questionnaires were received from 26 Member States for all three sites and from one Member State for breast cancer only. Substantial improvement in screening implementation using population-based approach was documented. Among the age-eligible women, 94.7% were residents of Member States implementing or planning population-based breast cancer screening in 2016, compared to 91.6% in 2007. The corresponding figures for cervical cancer screening were 72.3 and 51.3% in 2016 and 2007, respectively. Most significant improvement was documented for colorectal cancer screening with roll-out ongoing or completed in 17 Member States in 2016, compared to only five in 2007. So the access to population-based screening increased to 72.4% of the age-eligible populations in 2016 as opposed to only 42.6% in 2007. The invitation coverage was highly variable, ranging from 0.2-111% for breast cancer, 7.6-105% for cervical cancer and 1.8-127% for colorectal cancer in the target populations. In spite of the considerable progress, much work remains to be done to achieve optimal effectiveness. Continued monitoring, regular feedbacks and periodic reporting are needed to ensure the desired impacts of the programmes.

Disparities in time trends of cervical cancer mortality rates in Brazil.

PURPOSE: This study aimed to correct and describe cervical cancer mortality rates and trends by regions and age-groups in Brazil. It may help planning and implementing policies for cervical cancer control. METHODS: Data from 2003 to 2012 were accessed through the centralized national mortality database. Correction of the age-specific mortality rates was done by proportional redistribution of ill-defined causes of death and deaths coded as 'uterine, part unspecified'. Annual percentage change (APC) was obtained by trend analysis (Joinpoint regression). RESULTS: In the 10-year period, cancer and ill-defined causes corresponded, respectively, to 18.9 and 10.8 % of all deaths (except injuries). The proportion of ill-defined causes was reduced by more than a half in the period. The age-standardized cervical cancer mortality rate was 7.2 per 100,000 women-years after correction. The total increase in rates after corrections was 50.5 %. A significant decreasing trend in rates was observed at the national level (APC = -0.17, p < 0.001). North was the only region that did not show a decreasing significant trend (APC + 0.07, p = 0.28). Decreasing trends were restricted to age-groups over 40 years. CONCLUSIONS: A consistent decreasing trend of cervical cancer mortality rates in Brazil from 2003 to 2012 was observed, although this was not consistent in all regions and restricted to older age-groups. Quality of data needs to be improved. Cancer control policies may consider the differences in access to care and the characteristics of regions to improve their efficiency.

Usefulness of vaginal cytology tests in women with previous hysterectomy for benign diseases: assessment of 53,891 tests.

OBJECTIVE: To assess the value of vaginal screening cytology after hysterectomy for benign disease. METHODS: This cross-sectional study used cytology audit data from 2,512,039 screening tests in the metropolitan region of Campinas from 2000 to 2012; the object was to compare the prevalence of abnormal tests in women who had undergone a hysterectomy for benign diseases (n=53,891) to that of women who had had no hysterectomy. Prevalence ratios (95% confidence intervals, 95% CI) were determined, and chi-square analysis, modified by the Cochrane-Armitage test for trend, was used to investigate the effects of age. RESULTS: The prevalence of atypical squamous cells (ASC), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion or squamous-cell carcinoma (HSIL/SCC) was 0.13%, 0.04% and 0.03%, respectively, in women who had undergone hysterectomy, and 0.93%, 0.51% and 0.26% in women who had not undergone hysterectomy. The prevalence ratios for ASC, LSIL and HSIL/SCC were 0.14 (0.11-0.17), 0.08 (0.06-0.13) and 0.13 (0.08-0.20), respectively, in women with a hysterectomy versus those without. For HSIL/SCC, the prevalence ratios were 0.09 and 0.29, respectively, for women <50 or ≥50 years. The prevalence rates in women with a previous hysterectomy showed no significant variation with age. CONCLUSION: The prevalence rates of ASC, LSIL and HSIL/SCC were significantly lower in women with a previous hysterectomy for benign disease compared with those observed in women with an intact uterine cervix. This study reinforces the view that there is no evidence that cytological screening is beneficial for women who have had a hysterectomy for benign disease.

Protection against squamous cell carcinoma and cervical adenocarcinoma afforded by cervical cytology screening: a cross-sectional study.

OBJECTIVE: The objective of this study was to evaluate the impact of cervical cytology screening on the prevalence of cervical cytological results in women, as a function of age and test interval. METHODS: This is a cross-sectional study of cytology screening data of 2,002,472 tests obtained from previously screened women and 217,826 tests from unscreened women. The central cytopathology laboratory database was analyzed. The tests were collected for screening purposes from Campinas metropolitan region, Brazil. A prevalence ratio (PR) with a 95% confidence interval was calculated for the screened women, in relation to the unscreened women, and for different tests intervals. Protection afforded by screening (1-PR) was calculated. RESULTS: For high-grade squamous intraepithelial lesion, the PR was 0.97 (0.83-1.13) for women aged 20 years or younger and 0.99 (0.86-1.14) for women aged 20 to 24 years, decreasing significantly in women aged 25 to 29 years (PR, 0.63 [0.52-0.76]). The PR for squamous cell carcinoma, adenocarcinoma in situ (AIS), and invasive adenocarcinoma showed a significant reduction in all age groups older than 30 years. For the age group ranging from 30 to 59 years, protection for squamous cell carcinoma, AIS, and invasive adenocarcinoma was 83% or higher for screening intervals from 1 to 5 years. Protective effect was not demonstrated for screening intervals longer than 5 years for AIS and invasive adenocarcinoma. CONCLUSIONS: Cytology screening is effective at preventing cytological high-grade squamous intraepithelial lesion, squamous cell carcinoma, AIS, and invasive adenocarcinoma. On the basis of cytological results, protection against AIS and invasive adenocarcinoma was observed with screening intervals shorter than 5 years. Cytological screening in women 25 years or younger should be critically evaluated.

The impact of the COVID-19 pandemic on breast cancer screening and diagnosis in a Brazilian metropolitan area.

OBJECTIVES: To evaluate the performance of breast cancer screening and early diagnosis during the pandemic, compared to the pre-pandemic period.Setting: The public referral centre for screening in Campinas, São Paulo State, Brazil. METHODS: This is an audit study of performance screening and diagnostic indicators. Two periods were analysed: 2019, the pre-COVID period, and 2020, the COVID period. All women who underwent mammography in these periods were included. Indicators were compared between periods, and the US Breast Cancer Surveillance Consortium benchmarks were used as a reference. RESULTS: A comparison between the periods shows a reduction of 57.4% in screening and 4.4% in diagnosis using mammography. Cancer detection rate per 1000 screening mammograms dropped from 4.62 to 2.83 (p = 0.031), while it increased from 84.43 to 89.36 in diagnosis mammograms (p = 0.701), higher than the reference (34.4, p < 0.001). With regard to diagnosis, the proportion of minimal cancers was reduced (p = 0.005) and was lower than the reference (40.0%, p < 0.001), along with the proportion of node-negative invasive cancers (p < 0.001). The mean size of invasive tumours was similar in the two periods (32.50 mm and 33.40 mm, p = 0.808) but larger than the reference value (16.50 mm, p < 0.001). Recall rate was lower in the COVID period (22.55% vs. 27.37%, p = 0.015). CONCLUSION: The COVID pandemic caused an overall decrease in breast screening and detection of breast cancer cases, although the reduction in number of diagnosis mammograms performed was minimal. Tumour mean size was large in both periods, the pandemic highlighting a previous profile of detection at an advanced stage.

Prognosis determination of endocervical adenocarcinomas morphologically reclassified as HPV associated or HPV independent.

OBJECTIVE: To evaluate the prognosis of endocervical adenocarcinomas after reclassification according to the morphologic type based on the 2020 World Health Organization Classification. METHODS: A retrospective longitudinal study with cases admitted at the University of Campinas, Brazil, from 2013 to 2020. The sample included 140 cases morphologically reclassified: 100 cases as adenocarcinoma HPV-associated (HPVA), 17 as HPV-independent (HPVI), and 23 non-HPVA/HPVI. Clinic and pathologic variables were evaluated. Analyses were performed by χ2 , Fisher exact, and Mann-Whitney U tests, Kaplan-Meier curves, Log-rank test, and Cox regression. RESULTS: Compared with the HPVA group, advanced stage (FIGO Stage II+) was more frequent in the HPVI group (P = 0.009), which also showed older patients (P = 0.032), and a higher proportion of deaths (P = 0.006). The median overall survival (OS) differed between groups: 73.3 months in HPVA and 42.4 months in HPVI (P = 0.005). At the multivariate analysis, the risk of death was 6.7 (95% confidence interval 1.9-23.0) times higher in patients diagnosed in advanced stages. CONCLUSION: HPVI cases were more frequent in older patients, presenting at more advanced stages and with worse OS. The morphology-based approach of the new WHO classification appears to be prognostically valuable and applicable in lower- and middle-income settings.

Social inequalities in access to cancer screening and early detection: A population-based study in the city of São Paulo, Brazil.

OBJECTIVE: This study monitors trends in access to cancer screening, focusing on mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA), assessing the magnitude of inequality in the city of São Paulo from 2003 to 2015 according to education level. METHOD: This is a cross-sectional population-based study conducted with data from the 2003, 2008, and 2015 editions of the Health Survey of the City of São Paulo (ISA-Capital). Outcome variables were the proportion of mammography, Papanicolaou (Pap smear), and Prostate-Specific Antigen (PSA) tests according to the protocols. Inequality was measured by education level according to years of study. For static analysis, Poisson regression was used to estimate proportion ratios. RESULTS: The proportion of Pap smears remained stationary at a high level (>89%) throughout the study period, while access to mammography and PSA tests significantly increased in the 2003‒2015 period. The present results indicate inequalities in access to cancer screening due to education, and being more expressive for mammography and PSA tests. However, this inequality significantly decreased over the period analyzed comparing the most educated individuals with those with the lowest educational level. In addition, an increase in the proportion of tests performed in the Brazilian Unified Health System was identified, especially for mammography and PSA tests, in the period 2003‒2015. CONCLUSIONS: The inequalities observed in the access to preventive exams were influenced by the level of education. The offer of exams was expanded, more significantly for mammography and PSA, especially among the less educated group.

Cervical Cancer Screening with DNA-HPV Testing and Precancerous Lesions Detection: A Brazilian Population-based Demonstration Study.

OBJECTIVE: To evaluate the rates of precancerous lesions, colposcopy referral, and positive predictive value (PPV) by age groups of a population-based screening with DNA-HPV testing. METHODS: The present demonstration study compared 16,384 HPV tests performed in the first 30 months of the program with 19,992 women tested in the cytology screening. The colposcopy referral rate and PPV for CIN2+ and CIN3+ by age group and screening program were compared. The statistical analysis used the chi-squared test and odds ratio (OR) with 95% confidence interval (95%CI). RESULTS: The HPV tests were 3.26% positive for HPV16-HPV18 and 9.92% positive for 12 other HPVs with a 3.7 times higher colposcopy referral rate than the cytology program, which had 1.68% abnormalities. Human Papillomavirus testing detected 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected by cytology (p < 0.0001). The age group between 25 and 29 years old screened by HPV testing had 2.4 to 3.0 times more positivity, 13.0% colposcopy referral, twice more than women aged 30 to 39 years old (7.7%; p < 0.0001), and detected 20 CIN3 and 3 early-stage cancer versus 9 CIN3 and no cancer by cytology screening (CIN3 OR= 2.10; 95%CI: 0.91-5.25; p = 0.043). The PPV of colposcopy for CIN2+ ranged from 29.5 to 41.0% in the HPV testing program. CONCLUSION: There was a significant increase in detections of cervix precancerous lesions in a short period of screening with HPV testing. In women < 30 years old, the HPV testing exhibited more positivity, high colposcopy referral rate, similar colposcopy PPV to older women, and more detection of HSIL and early-stage cervical cancer.

OBJETIVO: Avaliar as taxas de lesões pré-cancerosas, encaminhamento para colposcopia e valor preditivo positivo (VPP) por faixas etárias de rastreamento populacional com teste DNA-HPV. MéTODOS: O presente estudo de demonstração comparou 16.384 testes de HPV realizados nos primeiros 30 meses do programa com 19.992 mulheres testadas no rastreio citológico. Os programas foram comparados por taxa de encaminhamento de colposcopia e VPP para NIC2+ e NIC3+ por faixa etária. A análise estatística utilizou o teste de qui-quadrado e odds ratio (OR, na sigla em inglês) com intervalo de confiança (IC) de 95%. RESULTADOS: Os testes de HPV foram 3,26% positivos para HPV16-HPV18 e 9,92% positivos para 12 outros HPVs, com uma taxa de encaminhamento de colposcopia 3,7 vezes maior do que o programa de citologia, que teve 1,68% de anormalidades. O teste de HPV detectou 103 NIC2, 89 NIC3 e um AIS, em comparação com 24 NIC2 e 54 NIC3 detectados por citologia (p < 0,0001). O rastreio por teste de HPV no grupo etário 25 a 29 anos teve 2,4 a 3,0 vezes mais positividade, 13,0% de encaminhamento para colposcopia, 2 vezes mais que mulheres de 30 a 39 anos (7,7%; p < 0,0001), e detectou 20 NIC3 e 3 cânceres em estágio inicial versus nove NIC3 e nenhum câncer pelo rastreio citológico (NIC3 OR= 2,10; 96%CI: 0,91­5,25; p = 0,043). O VPP da colposcopia para NIC2+ variou de 29,5 a 41,0% no programa de teste de HPV. CONCLUSãO: Houve um aumento significativo na detecção de lesões pré-cancerosas do colo do útero em um curto período de rastreamento com teste de HPV. Em mulheres < 30 anos, o teste de HPV exibiu mais positividade, alta taxa de encaminhamento para colposcopia com VPP semelhante a mulheres mais velhas, e mais detecção de HSIL e de câncer cervical em estágio inicial.