Increasing participation in cervical cancer screening: Telephone contact with long‐term non‐attendees in Sweden. Results from RACOMIP, a randomized controlled trial

Abstract

Non-participation is the foremost screening-related risk factor for cervical cancer. We studied the effectiveness and costeffectiveness of an intervention to increase participation in the context of a well-run screening program. Telephone contact with non-attendees, offering an appointment to take a smear, was compared with a control group in a population-based randomized trial in western Sweden. Of 8,800 randomly selected women aged 30-62, without a registered Pap smear in the two latest screening rounds, 4,000 were randomized to a telephone arm, another 800 were offered a high-risk human papillomavirus (HPV) self-test by mail (not reported in this article) and 4,000 constituted a control group. Endpoints were frequency of testing, frequency of abnormal smears and further assessment of abnormal tests. Participation during the following 12 months was significantly higher in the telephone arm than in the control group, 718 (18.0%) versus 422 (10.6%) [RR: 1.70, 95% confidence interval (CI): 1.52-1.90]. The number of detected abnormal smears was 39 and 19, respectively (RR: 2.05, 95% CI: 1.19-3.55). The respective numbers of further assessed abnormalities were 34 and 18 (RR: 1.89, 95% CI: 1.07-3.34). Twice as many high-grade intraepithelial neoplasia (CIN21) were detected and treated in the telephone arm: 14 and 7, respectively. Telephone contact with women who have abstained from cervical cancer screening for long time increases participation and leads to a significant increase in detection of atypical smears. Cost calculations indicate that this intervention is unlikely to be cost-generating and this strategy is feasible in the context of a screening program.Cervical cancer is considered to be a preventable disease. Screening by Papanicolaou (Pap) smear has markedly reduced incidence and mortality. [2][3][4] Vaccines to prevent infection with specific oncogenic human papillomavirus (HPV), the main cause of cervical cancer, 5 are available but it will be long before effects on cancer will be measurable. 6,7 At least until then, screening programs will remain the key defense against this disease.8 A recent audit of the Swedish screening program, in which all cases of invasive cervical epithelial carcinoma during 3 years were evaluated, showed that

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“…A study conducted in Malaysia also showed the lack of a proper follow‐up system for women taking screening tests . Annual reminders and scheduled appointments (with internet‐based rebooking of appointments) have already been implemented in Sweden . Organized programs that are implemented within existing health services, and include tools such as systematic call, recall, follow‐up, and surveillance, could also help to improve cervical cancer screening …”

“…13,14 Annual reminders and scheduled appointments (with internet-based rebooking of appointments) have already been implemented in Sweden. 15 Organized programs that are implemented within existing health services, and include tools such as systematic call, recall, follow-up, and surveillance, could also help to improve cervical cancer screening. 16 Nonetheless A study in Iran found that only 2% of women had been encouraged by radio and television broadcasts to take a cervical smear test.…”

The value of improving failures within a cervical cancer screening program: An example from Norway

“…Beyond modeling analyses, few clinical studies have assessed the effectiveness of interventions using health outcomes, but were unable to report on long‐term endpoints such as life expectancy, given the considerable time lag between detection and cancer‐related death. A recent Swedish randomized controlled trial registered upfront costs of a telephone‐based intervention and reported resource use in terms of total cost per additional detected case of high‐grade precancer . By applying a “rule of thumb” for the ratio of treated high‐grade lesions to averted CC case, the authors concluded that the telephone‐based intervention would likely be cost‐saving.…”

“…A recent Swedish randomized controlled trial registered upfront costs of a telephone-based intervention and reported resource use in terms of total cost per additional detected case of high-grade precancer. 25 By applying a "rule of thumb" for the ratio of treated high-grade lesions to averted CC case, the authors concluded that the telephonebased intervention would likely be cost-saving. Although such empirical studies are needed, only a relatively short time horizon and a limited number of scenarios are feasible.…”

Intervenções que favorecem a adesão ao exame de colpocitologia oncótica: revisão integrativa

“…Telephone call A study performed in Sweden comprising 8,800 women who had not undergone Pap smear exam for two years, using control and intervention groups, inferred that telephone calls increased women's participation in the uptake of the exam, are low cost, and can be carried out within the scope of a prevention program (11) . Automated call reminders were used in another cohort study in Texas, United States of America, comprising 32,807 women for a three-year period, which also showed an increased uptake of Pap smear exam (12) .…”