Prevalence of positive screening test results and agreement between cytology and human papillomavirus testing in primary cervical cancer screening in North-Western Romania.

Using data from a pilot study conducted in North-Western Romania, we aimed to estimate the prevalence of abnormal cytology and positive high-risk human papillomavirus (hr-HPV) test results in an ethnically diverse screening population and to assess the agreement between cytology and hr-HPV testing to evaluate the feasibility of integrating the latter as a primary test in the national cervical cancer screening program. The cross-sectional pilot study included Roma women, other ethnic minorities, and women in rural remote areas. Samples were taken for liquid-based cytology and hr-HPV testing (Hybrid Capture 2 DNA test) by a mobile health unit. The prevalence of positive screening results and the agreement between cytology and hr-HPV testing were estimated by κ coefficient. A total of 1019 women were included in the study. The population prevalence of positive screening results was similar for both tests (12%). The prevalence of abnormal cytology increased with increasing age, whereas the prevalence of positive hr-HPV test showed a bimodal age pattern. Substantial differences in the prevalence of abnormal cytology were found by ethnicity, with highest prevalence in Romanian women (14%), followed by Roma women (6%) and women of other ethnicities (5%) (P = 0.002). Similar ethnic differences in the prevalence of positive hr-HPV test were not observed. The overall agreement of positive screening results between the two methods was fair (κ = 0.25; 95% confidence interval = 0.18-0.30, P < 0.001) and ranged from poor to substantial depending on the age group. The prevalence of abnormal cytology result was high and similar to the prevalence of positive hr-HPV test result, which could allow for the implementation of hr-HPV testing as a primary test in the cervical cancer screening program in Romania.

Correction to: Attendance to cervical cancer screening among Roma and non-Roma women living in North-Western region of Romania.

Romania has Europe's highest incidence and mortality rates of cervical cancer. Participation in the national cervical cancer-screening programme is low, especially among minority Roma women.

Attendance to cervical cancer screening among Roma and non-Roma women living in North-Western region of Romania.

OBJECTIVES: Romania has Europe's highest incidence and mortality rates of cervical cancer. Participation in the national cervical cancer-screening programme is low, especially among minority Roma women. METHODS: We conducted a cross-sectional study, using a structured questionnaire aiming to quantify reasons for screening attendance among women in North-Western region of Romania. RESULTS: 980 women were enrolled in this study. Data were analysed using logistic regression, estimating odds ratios (OR) and 95% confidence intervals (CI). This study revealed that Roma women (46%) attended screening less frequently that non-Roma women (63%),; however, ethnicity in itself was not associated with screening attendance. Instead we found that attendance to the cervical cancer screening programme was determined by having ever heard about a screening opportunity (OR 5.90, 95% CI 3.76-9.27) and having three or more sex partners (OR 5.99, 95% CI 1.71-21.04). CONCLUSIONS: We concluded that information about the screening programme's existence and its rationale does not reach the women targeted for screening sufficiently and argue that a process of user involvement aiming to build contact, interaction and cooperation between the programme and its potential participants is warranted.

Incidence trends and survival of skin melanoma and squamous cell carcinoma in Cluj County, Romania.

The aim of this study was to determine the incidence trends of cutaneous melanoma (CM) and squamous cell carcinoma (SCC) in Cluj County, from 1998 to 2011, and the 5-year net survival between 2006 and 2010. Data on all cases of CM and SCC between 1998 and 2011 were obtained from Cluj Cancer Registry. Incidence rates were age standardized by the direct method Age Standardized Incidence Rate (ASIR), using the world standard population. Trends and annual percentage change (APC) of incidence rates were calculated by joinpoint regression analysis. The Pohar-Perme estimator was used to examine the 5-year net survival of cases diagnosed during 2006-2010 and followed up until December 2015. A total of 580 cases of CM and 397 cases of SCC were reported. During 1998-2011, the ASIR of CM increased significantly by 7.8% APC in male patients and by 7.42% APC in female patients, and the ASIR for SCC increased by 9.40% APC in male patients. In female patients, the incidence of SCC increased by 12.65% APC during 2002-2011. The 5-year net survival during 2006-2010 was 0.64 in men and 0.75 in women for CM and 0.86 and 1.00, respectively, for SCC. Survival rates showed an improving trend during 2006-2010, and were generally lower in men. Survival from both entities decreased with age and was lower in rural areas and in advanced stages in both sexes. This study reveals a rising incidence of cutaneous cancers in concordance with international trends. These data support the important role of primary and secondary prevention of skin cancers, focusing not only on melanoma, due to its lower survival, but also on SCC, in order to reduce their burden.

Controversies about cervical cancer screening: A qualitative study of Roma women's (non)participation in cervical cancer screening in Romania.

Romania has Europe's highest incidence and mortality of cervical cancer. While a free national cervical cancer-screening programme has been in operation since 2012, participation in the programme is low, particularly in minority populations. The aim of this study was to explore Roma women's (non)participation in the programme from women's own perspectives and those of healthcare providers and policy makers. We carried out fieldwork for a period of 125 days in 2015/16 involving 144 study participants in Cluj and Bucharest counties. Fieldwork entailed participant observation, qualitative interviewing and focus group discussions. A striking finding was that screening providers and Roma women had highly different takes on the national screening programme. We identified four fundamental questions about which there was considerable disagreement between them: whether a free national screening programme existed in the first place, whether Roma women were meant to be included in the programme if it did, whether Roma women wanted to take part in screening, and to what degree screening participation would really benefit women's health. On the background of insights from actor-network theory, the article discusses to what degree the programme could be said to speak to the interest of its intended Roma public, and considers the controversies in light of the literature on patient centred care and user involvement in health care. The paper contributes to the understanding of the health and health-related circumstances of the largest minority in Europe. It also problematizes the use of the concept of "barriers" in research into participation in cancer screening, and exemplifies how user involvement can potentially help transform and improve screening programmes.

Cervical cancer screening practices in central and eastern Europe in 2012.

The burden of cervical cancer in central and eastern Europe is generally higher compared to western or northern Europe due to a history of mostly opportunistic cervical cancer screening practices and due to the strong influence of political and economic changes in post-communist transition. This article describes the current cervical cancer screening practices, organizational plans for the future, and main obstacles that need to be overcome in 16 countries in central and eastern Europe: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and The former Yugoslav Republic of Macedonia. Unfortunately, only a few countries have managed to establish an organized and well-functioning cervical cancer screening program in recent years, whereas most countries in the region are still struggling with implementation-related issues of organized cervical cancer screening. Encouragingly, even in the countries where only opportunistic screening is performed, well-prepared plans and strategies have been established for switching to organized screening in the near future.

Trends in cervical cancer incidence and mortality in the Baltic countries, Bulgaria and Romania.

The burden of cervical cancer varies considerably in the European Union (EU). In this article, we describe trends in incidence of and mortality from this cancer in the two most affected areas: the Baltic countries (Estonia, Latvia and Lithuania) and Southeast Europe (Bulgaria and Romania). Incidence data were obtained from the national cancer registries. Data on population and number of deaths from uterine cancers were extracted from the World Health Organization mortality database. Mortality rates were corrected for inaccuracies in the death certification of not otherwise specified uterine cancer. Joinpoint regression was used to study the annual variation of corrected and standardized incidence and mortality rates. Changes were assessed by calendar period and age group, whereas the evolution by birth cohort was synthesized by computing standardized cohort incidence/mortality ratios. Joinpoint regression revealed rising trends of incidence (in Lithuania, Bulgaria and Romania) and of mortality (in Latvia, Lithuania, Bulgaria and Romania). In Estonia, rates were rather stable. Women born between 1940 and 1960 were at continuously increasing risk of both incidence of and mortality from cervical cancer. Although some quality issues in the registration of cancer and causes of death cannot be ignored, the trends indicate increased exposure to human papillomavirus infection and absence of effective screening programs. Rising trends of cervical cancer in the most affected EU member states reveal a worrying pattern that warrants urgent preventive actions.

Trends in cervical cancer incidence and mortality in Bulgaria, Estonia, Latvia, Lithuania and Romania.

OBJECTIVE: The burden of cervical cancer varies considerably in the European Union. In this paper, we describe trends in incidence of and mortality from this cancer in the five most affected member states. METHODS: Data on number of deaths from uterine cancers and the size of the female population of Estonia, Latvia, Lithuania, Bulgaria and Romania were extracted from the WHO mortality database. Mortality rates were corrected for inaccuracies in the death certification of not otherwise specified uterine cancer. Incidence data were obtained from the national cancer registries. Joinpoint regression was used to study the annual variation of corrected and standardized incidence and mortality rates. Changes by birth cohort were assessed for specific age groups and subsequently synthesized by computing standardized cohort incidence/mortality ratios. RESULTS: Joinpoint regression revealed rising trends of incidence (in Lithuania, Bulgaria and Romania) and of mortality (in Latvia, Lithuania, Bulgaria and Romania). In Estonia, rates were rather stable. Women born between 1940 and 1960 were at continuously increasing risk of both incidence of and mortality from cervical cancer. CONCLUSIONS: Rising trends of cervical cancer in the most affected EU member states reveal a worrying pattern that warrants urgent introduction of effective preventive actions as described in the European guidelines.

Cervical cancer assessment in Romania under EUROCHIP-2.

BACKGROUND: Inside the European project EUROCHIP-2, the Romania team has ruled out an assessment study regarding cervical cancer screening programs (CCS) in Romania, in Nov 2006-March 2007. The general purpose was to be aliened to European Council recommendations that states that an organized cervical screening program should be offered in all member states, in order to reduce the specific incidence and mortality. The aim of the study was to assess cervical cancer burden and current cervical cancer screening status in Romania and in various sub-regions (DR), and also to identify problems and barriers and to propose solutions for implementing an organized cervical cancer screening program at national level. METHODS: The study was based on a statistical survey and a comprehensive literature review of the most important European, national and regional papers or studies completed in this field. RESULTS: Over 2000-2006, a total number of 22,830 new cases and 12,763 deaths from cervical cancer was registered in Romania. In 2005, the crude rate of incidence varied largely in the 8 DR between 17.8-31.3 and mortality varied between 12.3-21.5. The proportion of women tested by DRs on total female population varied between 3.2%-0.6%; the highest screening activity was observed in region VI, where run the only organized CCS in Romania. In 2005, there were one GP per 578 female population aged 25-65; regarding the specialists in 2007 per country we had: 3,012 women aged 25-65 per one gynecologist, 21,195 women per one oncologist and 13,258 women per one histopathologist. DISCUSSION AND CONCLUSION: There were no major changes in policy screening over 2000-2006 correlated with no major difference in specific mortality in Romania. Significant differences in incidence and mortality between DRs were observed in 2005, which impose deeper analyzes of local conditions and resources and local strategies to be adopted. The burden of cervical cancer is particularly high in Romania and is related to the absence of an organized CCS program or the ineffectiveness of the opportunistic screening programs. It is needed that European Council recommendations be implemented and quality assurance strategies to be checked and maintained at all screening levels in Romania.

Process performance of cervical screening programmes in Europe.

Standardised tables of aggregated data were collected from 15 European national or regional cervical screening programmes and key performance indicators computed as reported in European Union (EU) Guidelines, 2nd edition. Cytological results varied widely between countries both for the total proportion of abnormal tests (from 1.2% in Germany (Mecklenburg-Vorpommern) to 11.7% in Ireland-Midwest Region) and for their distribution by grade. Referral rates for repeat cytology (ranging from 2.9% of screened women in the Netherlands to 16.6% in Slovenia) or for colposcopy (ranging from 0.8% in Finland to 4.4% in Romania-Cluj) and the Positive Predictive Value (PPV) of colposcopic attendance (ranging from 8% in Romania-Cluj to 52% in Lithuania) were strongly influenced by management protocols, in particular for atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) cytology. However, cytology-specific PPV also showed remarkable variability. The detection rate of CIN2+ histology ranged from <0.1% of screened women in Poland to >1% in England and Denmark. Low attendance for colposcopy after referral was observed in some east-European countries. These comparisons may be useful for improving the performance of cervical screening in general and more so if new screening technologies and vaccination for Human Papillomavirus are introduced. Overall, quality was better in countries that have operated organised programmes for a longer time, plausibly as a result of long-lasting monitoring and quality assurance activities. Therefore, the availability of these data, the first comparing European countries, and the increased number of countries that can provide such data (only five in 2004) represent progress. Nevertheless, there is a clear need to standardise the cytological and histological classifications used in screening, as well as data registration systems across Europe.

The burden of cervical cancer in south-east Europe at the beginning of the 21st century.

The situation of cervical cancer prevention in South-East Europe is hardly documented, in spite of the fact that it encloses the most affected countries of Europe. We estimated the number of cases of cervical cancer, the number of deaths from this malignancy and the corresponding rates for 11 countries located in South-East Europe, in the period 2002-2004. Each year, approximately 9,000 women develop cervical cancer and about 4,600 die from the disease in this subcontinent. The most affected country is Romania with almost 3,500 cases and more than 2,000 deaths per year High world-age standardised mortality rates (> 7.5 [expressed per 100,000 women-years]) are observed in 7 countries: FYROM (7.6), Moldova (7.8), Bulgaria (8.0), Bosnia & Herzegovina (8.0), Albania (9.8), Serbia & Montenegro (10.1) and Romania (13.0). A matter of concern is the increasing mortality rate, in younger women, in the countries with the highest burden of cervical cancer. Thus, appropriate cervical cancer prevention programmes should be set up without delay in this part of Europe.