Introduction of primary screening using high-risk HPV DNA detection in the Dutch cervical cancer screening programme: a population-based cohort study.

BACKGROUND: In January 2017, the Dutch cervical cancer screening programme transitioned from cytomorphological to primary high-risk HPV (hrHPV) DNA screening, including the introduction of self-sampling, for women aged between 30 and 60 years. The Netherlands was the first country to switch to hrHPV screening at the national level. We investigated the health impact of this transition by comparing performance indicators from the new hrHPV-based programme with the previous cytology-based programme. METHODS: We obtained data from the Dutch nationwide network and registry of histo- and cytopathology (PALGA) for 454,573 women eligible for screening in 2017 who participated in the hrHPV-based programme between 1 January 2017 and 30 June 2018 (maximum follow-up of almost 21 months) and for 483,146 women eligible for screening in 2015 who participated in the cytology-based programme between 1 January 2015 and 31 March 2016 (maximum follow-up of 40 months). We compared indicators of participation (participation rate), referral (screen positivity; referral rate) and detection (cervical intraepithelial neoplasia (CIN) detection; number of referrals per detected CIN lesion). RESULTS: Participation in the hrHPV-based programme was significantly lower than that in the cytology-based programme (61% vs 64%). Screen positivity and direct referral rates were significantly higher in the hrHPV-based programme (positivity rate: 5% vs 9%; referral rate: 1% vs 3%). CIN2+ detection increased from 11 to 14 per 1000 women screened. Overall, approximately 2.2 times more clinical irrelevant findings (i.e. ≤CIN1) were found in the hrHPV-based programme, compared with approximately 1·3 times more clinically relevant findings (i.e. CIN2+); this difference was mostly due to a national policy change recommending colposcopy, rather than observation, of hrHPV-positive, ASC-US/LSIL results in the hrHPV-based programme. CONCLUSIONS: This is the first time that comprehensive results of nationwide implementation of hrHPV-based screening have been reported using high-quality data with a long follow-up. We have shown that both benefits and potential harms are higher in one screening round of a well-implemented hrHPV-based screening programme than in an established cytology-based programme. Lower participation in the new hrHPV programme may be due to factors such as invitation policy changes and the phased roll-out of the new programme. Our findings add further to evidence from trials and modelling studies on the effectiveness of hrHPV-based screening.

Benefits and harms of breast cancer screening with mammography in women aged 40-49 years: A systematic review.

Early detection of breast cancer through screening can lower breast cancer mortality rates and reduce the burden of this disease in the population. In most western countries, mammography screening starting from age 50 is recommended. However, there is debate about whether breast cancer screening should be extended to younger women. This systematic review provides an overview of the evidence from RCTs on the benefits and harms of breast cancer screening with mammography in women aged 40-49 years. The quality of the evidence for each outcome was appraised using the GRADE approach. Four articles reporting on two different trials-the Age trial and the Canadian National Breast Screening Study-I (CNBSS-I)-were included. The results showed no significant effect on breast cancer mortality (Age trial: RR 0.93 (95% CI 0.80-1.09); CNBSS-I: HR 1.10 (95% CI 0.86-1.40)) nor on all-cause mortality (RR 0.98, 95% CI 0.93-1.03) in women aged 40-49 years offered screening. Among regularly attending women, the cumulative risk of experiencing a false-positive recall was 20.5%. Over-diagnosis of invasive breast cancer at 5 years post-cessation of screening for women aged 40-49 years was estimated to be 32% and at 20 years post-cessation of screening to be 48%. Including ductal carcinoma in situ, these numbers were 41% and 55%. Based on the current evidence from randomised trials, extending mammography screening to younger age groups cannot be recommended. However, there were limitations including relatively low sensitivity of screening and screening attendance, insufficient power, and contamination, which may explain the nonsignificant results.

Interventions to enhance informed choices among invitees of screening programmes-a systematic review.

BACKGROUND: Informed decision making about participation has become an explicit purpose in invitations for screening programmes in western countries. An informed choice is commonly defined as based on: (i) adequate levels of knowledge of the screening and (ii) agreement between the invitee's values towards own screening participation and actual (intention to) participation. METHODS: We systematically reviewed published studies that empirically evaluated the effects of interventions aiming at enhancing informed decision making in screening programmes targeted at the general population. We focused on prenatal screening and neonatal screening for diseases of the foetus/new-born and screening for breast cancer, cervical cancer and colorectal cancer. The Medline, EMBASE and Cochrane databases were searched for studies published till April 2012, using the terms 'informed choice', 'decision making' and 'mass screening' separately and in combination and terms referring to the specific screening programmes. RESULTS: Of the 2238 titles identified, 15 studies were included, which evaluated decision aids (DAs), information leaflets, film, video, counselling and a specific screening visit for informed decision making in prenatal screening, breast and colorectal cancer screening. Most of the included studies evaluated DAs and showed improved knowledge and informed decision making. Due to the limited number of studies the results could not be synthesized. CONCLUSION: The empirical evidence regarding interventions to improve informed decision making in screening is limited. It is unknown which strategies to enhance informed decision making are most effective, although DAs are promising. Systematic development of interventions to enhance informed choices in screening deserves priority, especially in disadvantaged groups.

Identification of socioeconomic groups at increased risk for smoking in European countries: looking beyond educational level.

Educational level is most often used to identify social groups with increased prevalence of smoking. Other indicators of socioeconomic position (SEP) might, however, be equally or even more discriminatory. This study examined the extent to which smoking behavior is related to other socioeconomic indicators in addition to educational level. Data were derived from the European Household Panel. We selected data for 45,765 respondents aged 25-60 years from nine European countries. The association between six different SEP indicators and smoking prevalence was examined using prevalence rate ratios (RRs) estimated through log linear regression analyses. In univariate analyses, most selected SEP indicators were associated with smoking. In multivariate analyses, educational level, occupational class, accumulated wealth (measured by household assets), and housing tenure retained independent effects on smoking (RRs about 1.20). The effects observed for activity status and household income were small and insignificant in nearly all populations. In northern Europe, educational level had the greatest predictive value in the younger age groups; occupational class and housing tenure predicted most of smoking prevalence in the older age groups. The results showed a less pronounced and more varied pattern in southern Europe. Our results indicate that smoking prevalence is related not only to educational level but also to occupational class and measures of accumulated wealth (other than income). These measures should be used in addition to educational level to identify groups at increased risk for smoking.

A cluster-randomized trial of screening for language delay in toddlers: effects on school performance and language development at age 8.

OBJECTIVE: The goal of this study was to assess the effects of screening and early treatment of preschool children for language delay on language development and school performance at age 8. METHODS: A cluster-randomized, controlled trial and follow-up study of 55 child health centers in 6 geographic regions were conducted from January 2002 to September 2005. A total of 9419 children who were from the general population and aged 15 months at entry were studied. School type end school progress was known for 5406 (57.4%) children. In the intervention group, a structured screening instrument was conducted twice (at ages 15/18 and 24 months), and usual care was applied in the control group. The screening instrument consisted of a uniform set of questions for the parents and test elements for the child. A positive screen result was followed by multidisciplinary assessments at speech and hearing centers and subsequent early treatment if needed. Percentages of children who attended a special school, repeated a class because of language problems, and scored low on standardized language tests, in intention-to-screen analyses, were measured. RESULTS: At age 8, 2.7% in the intervention group and 3.7% in the control group attended a special school, 6.1% vs 4.9% had repeated a grade, 8.8% vs 9.7% had deficient oral language performance, 4.7% vs 4.7% had deficient reading, and 2.8% vs 4.2% had deficient spelling. CONCLUSIONS: Screening toddlers for language delays reduces the number of children who require special education and leads to improved language performance at age 8. Nationwide implementation of the screening might be recommended.

Quality of life of children with language delays.

We investigated health-related quality of life (HRQOL) of children with language problems and controls. Data on language development (Language Screening Instrument 3-years-olds, Van Wiechen items) and HRQOL by means of the TNO-AZL Pre-school children Quality of Life-questionnaire (TAPQOL) were collected at age 3 in a population-based cohort by parental questionnaire (n = 8877, response 78%; mean age 39.1 months (SD 2.0), 4347 were girls). Cronbach's alpha (internal consistency) ranged between 0.63 and 0.85. Dependent on the definition of language problem, 131 to 316 children appeared to be language impaired. Receiver Operating Characteristic analyses (ROC-curves) to assess the discriminative ability of six TAPQOL scales revealed that the Communication scale and Social Functioning scale discriminated best between children with language problems and children without these problems. Language-impaired children had significantly lower scores on the Communication scale and Social Functioning scale as compared to children without language problems (p < 0.01). The findings indicate that language problems at age three can have an impact on children's social life. These results provide additional evidence for the importance of monitoring the language development and its consequences during childhood.