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The coverage and quality of screening are essential for reducing the incidence of cervical precancers and cervical cancer. This multicenter study aimed to investigate the relationship between screening quality and the detection of cervical precancers and cervical cancer. The study was conducted from June to December 2021 in six hospitals across six provinces. The 2,945 participants were non-pregnant women who underwent colposcopy examinations. The average age of participants was 40.9±11.5 years old. Only 6.9% of participants had received human papillomavirus (HPV) vaccination. A total of 92.6% of participants had abnormal cervical screening results. Of the participants, 577 had high-grade squamous intraepithelial lesions (HSIL) or worse (≥HSIL), with a detection rate of 19.6%. Univariate analysis indicated that a lack of cervical cancer screening history in the past five years, as well as positive cervical screening and abnormal colposcopic impression, were independent associated factors of the ≥HSIL detection rate. A multivariable logistic regression showed that positive cervical screening [odds ratio (OR) =1.75, 95% confidence interval (CI): 1.07–2.86] was a risk factor for detecting ≥HSIL. Low-grade, high-grade, and cancer of colposcopic impression were associated with a higher risk for detecting ≥HSIL (OR=2.94, 95% CI: 2.13–4.08; OR=36.64, 95% CI: 26.07–51.48). It is important to disseminate health knowledge to improve public awareness of cervical cancer prevention and to enhance the capacity building of professional staff to improve the quality of cervical cancer screening.
Cervical cancer was the second most common cancer and the second leading cause of cancer-related death among women of reproductive age worldwide in 2020, with 604,127 new cases and 341,831 deaths (1). Of these, 88.1% of the new cases and 91.4% of the deaths occurred in low- and middle-income countries. In 2016, China reported 98,900 new cases and 30,500 deaths due to cervical cancer (2). Cervical cancer can be prevented through vaccination and screening with appropriate follow-up and treatment (3). Early detection and treatment of cervical precancers are also key to successful prevention. Cervical precancers include HSIL and adenocarcinoma in situ (AIS). Cervical cancer screening, colposcopy, and pathology are three steps for diagnosing cervical precancers. Therefore, the coverage and quality of screening are essential to reducing the incidence of cervical precancers. The objective of this multicenter study was to investigate the relationship between screening quality and the detection of cervical precancers and cervical cancer in hospitals, providing evidence to improve cervical control for the target population in health facilities.
The study sites were six hospitals in six provincial-level administrative divisions (PLADs): Peking University First Hospital, Sichuan Provincial Maternity and Child Health Care Hospital, Women’s Hospital School of Medicine Zhejiang University, Yanbian Maternal and Child Health Care Hospital, Changzhou Maternal and Child Health Care Hospital, and Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. The participants were all non-pregnant women who underwent colposcopy examination in the study hospitals from June to December 2021. A biopsy was performed after colposcopy examination, followed by biopsy specimens for pathological diagnosis. The collected data included age, cervical cancer screening history, HPV vaccination, cervical cancer screening, colposcopy examination, and pathology results. All the colposcopy doctors in the six hospitals had received training in colposcopy operations. The study was approved by the Biomedical Research Ethics Committee of Peking University First Hospital, with the ethic code 2020[321]. Finally, among 3,637 women, 2,945 participants were analyzed. The exclusion criteria included incomplete data collection. The outcome of this study was the detection of cervical precancers and cervical cancer (≥HSIL). SPSS software (version 26.0, IBM, Armonk, NY, USA) was used for statistical analyses, and P<0.05 was considered a statistically significant difference. Continuous variables were expressed as mean±standard deviation (SD); categorical variables were expressed as numbers and percentages; comparisons among groups were performed by Chi-square tests or Fisher exact tests as appropriate. Multivariable logistic regression models were used to evaluate the association between risk factors and detection of ≥HSIL.
The average age of participants was 40.9±11.5, ranging from 19 to 80 years old; 17.4% (511/2,945) were ≤29 years, 34.1% (1,003/2,945) were 30–39 years, 23.6% (696/2,945) were 40–49 years, 18.2% (536/2,945) were 50–59 years, and 6.8% (199/2,945) were ≥60 years. Only 6.9% (204/2,945) of participants had received HPV vaccination, with 4.3% (127/2,945) having completed the three-dose regimen. Additionally, 50% (1,473/2,945) of participants had a cervical cancer screening history within the past five years.
Among 2,945 participants, 80.6% (2,373/2,945) received HPV combined cytology co-testing screening, while 19.4% (572/2,945) received cytology screening. Overall, 92.6% had abnormal cervical screening results, including cytology ≥atypical squamous cells of undetermined significance (ASC-US) or HPV positive, or both abnormal cytology results and HPV positive. Only 7.4% underwent colposcopic examinations for abnormal symptoms. According to the colposcopic impression, 34.1% (1,004/2,945) of participants were normal/benign, 48.4% (1,426/2,945) were low-grade, 16.0% (470/2,945) were high- grade, and 1.5% (45/2,945) were cancer. Through biopsy and pathology diagnosis, 80.4% (2,368/2,945) were ≤low-grade squamous intraepithelial lesions (LSIL); 537 participants were HSIL, and the percentage was 18.2%; 13 participants were AIS, and the percentage was 0.4%. Additionally, 27 women (0.9%) were diagnosed with invasive cervical cancer (ICC). The participants with ≥HSIL totaled 577, and the detection rate was 19.6%. Of these 577 participants with ≥HSIL, 471 (81.6%) had HPV combined cytology co-test for cervical cancer screening and 106 (18.4%) had cytology tests for cervical cancer screening (Figure 1).
Figure 1.Distribution of ≥HSIL with different screening methods (n, %) — six provinces, China, June–December 2021.
Abbreviation: HSIL=high-grade squamous intraepithelial lesion; HPV=human papillomavirus.The results of Table 1 indicated that a lack of cervical cancer screening history within the past 5 years, as well as a positive cervical screening and an abnormal colposcopic impression, were independent associated factors of ≥HSIL detection. The results of multivariable logistic regression to evaluate the associations between clinical risk factors and ≥HSIL are presented in Table 2. Positive cervical screening was found to be a risk factor for detecting ≥HSIL (OR=1.75, 95% CI: 1.07–2.86). Additionally, low-grade, high-grade, and cancer of colposcopic impression were associated with a higher risk for detecting ≥HSIL (OR=2.94, 95% CI: 2.13–4.08; OR=36.64, 95% CI: 26.07–51.48).
Clinical risk factor ≤LSIL*, n (%) ≥HSIL*, n (%) χ2 P Age (years) 5.38 >0.05 ≤29 405 (79.3) 106 (20.7) 30–39 792 (79.0) 215 (21.0) 40–49 572 (82.2) 124 (17.8) 50–59 443 (82.6) 93 (17.4) ≥60 156 (77.9) 43 (22.1) HPV vaccination 4.93 >0.05 Yes 163 (79.9) 41 (20.1) No 2,205 (80.4) 536 (19.6) Cervical cancer screening history in 5 years 32.82 <0.001 Yes 1,137 (82.7) 217 (17.3) No 1,158 (78.1) 320 (21.9) Unknown 73 (64.5) 40 (35.4) Cervical cancer screening method 0.51 >0.05 Cytology 466 (81.5) 106 (18.5) HPV combined cytology co-test 1,902 (80.2) 471 (19.8) Cervical cancer screening results this time 13.10 <0.001 Abnormal 2,018(79.4) 525 (20.6) Normal 350(87.1) 52 (12.9) Colposcopic impression† 759.68 <0.001 Normal/benign 953 (94.9) 51 (5.1) Low-grade 1,237 (86.7) 189 (13.3) High-grade 177 (37.7) 293 (62.3) Cancer 1 (2.2) 44 (97.8) Abbreviation: HSIL=high-grade squamous intraepithelial lesion; LSIL=low grade squamous intraepithelial lesion; HPV=human papillomavirus.
* ≤LSIL includes normal cervix and LSIL; ≥HSIL included HSIL and ICC.
† The Fisher exact test was used due to the small sample size of one cell (<5).Table 1. Characteristics of participants by detection of ≥HSIL (n, %) — six provinces, China, June–December 2021.
Risk factor Detection of ≥HSIL OR* 95% CI P Cervical cancer screening results Normal Ref. Abnormal 1.75 1.07–2.86 <0.050 Colposcopic impression Normal/benign Ref. Low-grade 2.94 2.13–4.08 <0.001 High-grade and malignant cancers 36.64 26.07–51.48 <0.001 Abbreviation: HSIL=high-grade squamous intraepithelial lesion; CI=confidence interval; OR=odds ratio.
* Adjusted for age, HPV vaccination, and cervical cancer screening history in the past 5 years.Table 2. Multiple logistic regression analysis of related clinical factors on detection of ≥HSIL — six provinces, China, June–December 2021.
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