Results of a Cervical Cancer Screening Program in Samsun, Turkey | BMC Women’s Health

Women are at risk of HPV infection becoming chronic and precancerous lesions developing into cervical cancer. Sexually active women should be screened for abnormal cervical cells and precancerous lesions beginning in their 30s [13]. The HPV screening program initiated in Germany in 2014 also targets this age group and is carried out by general practitioners. Analyzing country data, it was observed that the number of women participating in the screening program increased in subsequent years [9]. According to our province’s data, although the number of women screened varies over the years, positivity may have increased over the years as the younger age group was included in the screening. Additionally, the fact that GPs repeatedly invite women onto their screening lists, as dictated by legislation and national campaigns, can lead to increases in positivity rates over the years. Taking into account the 5-year screening results in our study, the HPV positivity rate was found to be 4.9%, and the rate of abnormal cytologies was 15.2% among the positives.

Today, the HPV-based screening test is replacing cytology because it is more effective in protecting against cervical cancer, offers longer screening intervals, and is less expensive [14, 15]. WHO has also called for a global call to emphasize the importance of screening with vaccination as part of a triple intervention strategy to eradicate cervical cancer [16].

HPV testing is used for screening purposes in many countries such as the United States, Australia, the Netherlands, Italy, Norway and Sweden [17,18,19]. HPV positivity can indicate different results depending on the region. In a study sharing the first results of the cervical cancer screening program conducted in our country, it was found that the HPV positivity rate was 3.5% and the rate of abnormal cytology was 19.1%. [9]. Looking at the HPV positivity in different countries, it is 8.1% in the screening conducted in Australia and 9.9% in the general population in the Asian continent [20, 21]. While it ranges from 43.8 to 55.8% in various studies conducted in Kazakhstan, it was 22.49% in a study conducted in China and 19.7% in the Caribbean [22,23,24]. These differences in the geographic distribution of HPV positivity can be linked to many factors such as sociocultural differences in societies, perceptions of risky behavior, and sexual experiences at an early age. It is reported that 70-80% of sexually active women are infected with HPV, usually shortly after beginning sexual activity [25]. Therefore, sexual behaviors such as active sex life, unsafe sex, and polygamy increase the risk of contracting HPV. HPV positivity in our study decreases with age, similar to other studies, and when evaluated in terms of oncogenic HPV types, these subtypes are more prevalent at younger ages [9, 20, 24]. We believe this is related to early and frequent intercourse.

In our study, the rate of HPV 16/18, which is considered an oncogenic type in HPV-positive women, was 31.7%. This rate was in the results of the study by Gültekin et al. at 33.22% [9]. Furthermore, the study found that in developing countries like Turkey, HPV 16-18 genotyping is sufficient to refer the patients for colposcopy in terms of both cost and human resources. While the risk of developing squamous cell carcinoma of the cervix is ​​low in women who are not infected with HPV, this risk increases 250 to 400 times in those who are infected [26]. It is also believed that this genotyping will fill the need for epidemiological mapping and provide detailed data to guide policy design related to HPV prevention, vaccination and screening.

When the Pap smear results of HPV positive women were examined in our study, 15.1% had abnormal cytology. The rate of abnormal cytology in HPV-positive women was 8.8%, 24.4% and 30.4% in studies conducted in different cities of our country [27,28,29]. In our study, ASC-US and LSIL results were very close when evaluating HPV-positive women for abnormal cytologic results. After that, the results were listed as AGC, ASC-H and HSIL. For country results, LSIL came first, followed by ASC-US and HSIL respectively [9]. Because various risk factors (such as multiparity, oral contraceptive use, smoking, and immunosuppression) are known to increase the risk of HSIL in HPV-infected women, we believe the difference is due to this situation [30]. It is noteworthy that in 484 (35.0%) of 1379 women who participated in the screening program and were HPV 16/18 positive, the cytology result was normal, suggesting that HPV scanning is more effective than cytology , similar to the literature [17, 31, 32].

The WHO global call emphasized that not every country should meet the 90-70-90 targets by 2030 to embark on the path to cervical cancer elimination in the next century [6]. The HPV vaccine is currently used in many countries and it is believed that the results of the national screening program will guide the studies on the use of this vaccine in our country. Various studies are being conducted to increase coverage rates in countries implementing screening programs and studies on self-HPV sampling are also being developed. These studies find that self-sampling is beneficial in removing barriers to clinician screening [33,34,35,36]. In studies of our country, the gynecological examination is considered one of the obstacles in the early detection of cervical cancer. [37,38,39]. The study by Sözmen et al. revealed that the number of women participating in cancer screening in our country is small [38]. Studies in different regions have shown that barriers to cervical cancer screening programs are similar. Among them, embarrassment, fear of physical privacy, fear of pain, fear of cancer, and concern about what the test will show rank among the top spots. Missing information is also a major obstacle. In a study of Muslim women, in addition to similar obstacles, social support, short processing times and responsibility for protecting one’s own health due to religious beliefs were found to be reasons for relief [40,41,42,43,44].

Because this is a retrospective study, we could not determine why women in the screening group did not accept the screening in our study. Given that we are a country with a majority Muslim population, it is believed that religious belief and cultural structure along with obstacles in other studies have an impact. Situations such as lack of information, lack of knowledge of health services or difficulties in accessing them may be due to the geographical structure of our city, among other things. For this reason, awareness-raising activities should be planned according to regional specificities and aim to reach all parts of society, especially through primary health care workers. In addition, we think that the self-test method will be useful to achieve the desired goal in the number of scans.

Our study has some limitations. One of them is that, apart from the age of the women, no further demographic variables (e.g. level of education, occupation, chronic illness) were available since the data collection from the automation program. Another limitation was that not all follow-up results of women who participated in the screening program and were HPV positive could be reached. Also, it was only performed on women admitted to health care facilities, and the number of women admitted to screening programs was small.

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