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Cervical Cancer and Screening in Denmark

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Cervical Cancer and Screening in Denmark ing of smears is carried out both in Cervical cancer and screening in hospital departments of pathology and Denmark by pathologists in private practice. As the smear-taking activity is neither centralized nor coordinated it is sus­ pected that the activity implies an un­ necessarily frequent screening of the ELSEBETH L YNGE AND ARNE BERGET majority of the highly motivated women - that is once a year - but does not reach poorly motivated women to a sufficient extent. According to information from In Denemark n functioncren naa t elkaar vcrschill ndc syst m n the organized screening programmes om cervixcarcinoom in cen vrocg stadium op te sporen. In enkclc the last group includes women at great­ di tricten makcn vrouwcn met de hun tocgczonden pipctlcn als est risk of cervical cancer. -I 5 het ware hun igen uitstrijkje. In andere streken krijgen vrouwcn Due to the complicated structure it is difficult to obtain statistical information van de regionalc gezondheidsdien t periodick bcricht dat hettijd on the smear-taking activity in Den­ wordt om zich (weer) voor cen uitstrijkje tot de huisarts Ie mark. However, it is estimated that a wenden. aarnaast kent men in Dencmarken ook de in cdcr­ total of 550,000 smears were taken in land bekcndc system n. 1980; a sufficient number to cover the Het volgende artikel werd op verzo k van de rcdacticcommissie whole female population with an or­ voor dit themanummer geschrcven. ganized programme including one smear every second or third year. 6 Hospital departments. Pap smears were Cervical cancer in Denmark mainly women below age 60 have beni­ taken in hospital departments of gy­ fited from the subsequent decline. Con­ necology and obstetrics in the Copenha­ In Denmark 300 deaths per year are due sequently, a changing age pattern is gen area in the mid 1950's but Pap to cervical cancer, 600 new cases of observed; the highest incidence was smears did not become a common tool cervical cancer are diagnosed, and 1150 seen previously around age 40-50, in gynecological departments in Den­ cases of carcinoma in situ and 1350 cases whereas the highest incidence in recent mark before the late 1960's. All smears of dysplasia are notified yearly to the years is seen around age 60-70. 3 S taken in hospitals are analyzed by the Danish Cancer Registry. I hospital departments of pathology. The incidence of cervical cancer is high Pap smears in Denmark compared with the inci­ GPs and private gynecologists. All ser­ dence in most other countries. In the A nation-wide screening programme for vice provided by GPs and private mid 1970's the age standardized rate cervical cancer and its precursors has specialists in Denmark is covered by the (world popUlation) was 23 .0 in Den­ never been established in Denmark, but national health insurance scheme. Pay­ mark compared with 12.7,8.5 and 19.0 some counties and municipalities have ment to private pathologists for analysis respectively in Sweden, Finland and locally organized programmes. Pap of smears became part of the agreement Norway. Cancer incidence figures from smears are taken in Denmark both by between the Medical Association and areas in other European countries show hospital departments and out patient the National Health Insurance in 1965, that the incidence rate in Denmark clinics , by GPs and private gynecologists and payment to GPs for smears became comes close to incidence rates from as a part of the normal clinical work, and part of the agreement in 1969. For pri­ GDR, Hamburg and Saarland, whereas by GPs and women themselves in or­ vate gynecologists no special fee is paid incidence rates from areas within both ganized screening programmes. Read- for smears, as these are considered a the UK, France, Switzerland, Hungary, natural part of a gynecological examina­ Italy and Spain are below. 2 Table 1. Incidence of invasive cervical tion. In 1943-47 an annual number of 600 cancer in Denmark, 1943-1982. cases of invasive cervical cancer were Local screening programmes. It is up to registered in Denmark. In 1963-67 the Pcriod Yearly Standardizcd the single counties in Denmark to de­ annual number had increased to 900; numher rute per cide whether they want to set up an but in 1978-82 the number had de­ of 100.1)00 organized screening programme or not. ca,c, creased again to 600. During the last twenty years ten or­ Table 1 shows that the age standardized 1943-47 587 24.5 ganized programmes were commenced rate (world population) increased from 1948-52 671 26.3 (table 2). The early programmes con­ 24.5 annual cases per 100,000 women in 1953-57 760 28.5 centrated on women aged 40-50, but the 1943-47 to a maximum of 31.7 annual 1958-62 858 31.1 age of invited women has gradually de­ cases per 100.000 women in 1963-67. 1963-67 904 31.7 clined over the years. By 1980 some 40 The so far lowest age standardized rate 1968-72 805 27 .2 per cent of women aged 30-49 were was seen in 1978-82 with 18.3 annual 1973-77 714 22.3 covered by the organized programmes. cases per 100.000 women. The increase 1978-82" 616 18.3 A programme based on mailed pipettes in the incidence from 1943-47 to 1963-67 is coordinated from a central National effected all women above age 30, but .• Preliminary figure, Health Insurance office in the county. 412 Huisarts en Wetenschap 1984; 27 The pipettes are mailed directly to the Table 2. Screening programs in Denmark. private addresses on women in the Year Place Method selected age-groups. Used pipettes are returned to the central office from 1962 Frederiksborg municipality Mailed pipettes which they are distributed to depart­ 1967 Storstrom county Smears taken by GP's ments of pathology within the county. 1967 Copenhagen municipality Mailed pipettes Women with positive pipettes are called 1967 Samso (small island) Smears taken by GP's, pipettes for examination in the out-patient clinic distributed by GP's at a county hospital. In a programme based on smears taken 1968 Copenhagen county Smears taken by GP's by GPs letters are send to women in the 1972 Frederiksborg county Mailed pipettes selected age-groups inviting them to 1975 Roskild county Mailed pipettes visit their G P for a gynecological exami­ 1979 Vejle county Smears taken by GP's nation. Smears taken by GPs are re­ 1979 Sonderjylland county Smears taken by GP's turned to the central office and further 1981 Bornholm county Smears taken by GP's distributed to pathological depart­ ments. In counties with organized pro­ grammes GPs are paid a special fee for Table 3. Smear-taking-activity in selected counties in 1979. Number of smears per smear-taking and completing a ques­ woman aged 20-59. tionnaire. If a smear is positive the County GP's Programme Hospital Total department of pathology will inform the GP, and the GP will contact the patient GP's Women for further follow-up. Frederiksborg .23 .27 .10 .60 Distribution of smears Storstr0m ,13 ,12 .09 .34 Arhus .22 ,08 .30 ,03 ,09 ,37 In 1979 a total of 470,000 smears were All counties .23 .03 taken outside the Copenhagen area; approximately 56 per cent were taken Figure. Organization of the smear-taking activity in Denmark. by GP on clinical indication, 31 per cent by hospital departments. and 13 per cent by GPs or the women themselves in organized programmes. An equivalent Smears are Smears are calculation can not be made for the taken by: analyzed by: Copenhagen area due to a special agree­ ment for GPs in these municipalities. There is a great difference between counties in the distribution of smears by source depending on whether the coun­ CPs as part ty runs an organized programme or not. of clinical Table 3 shows the number of smears per work women aged 20-59 in 1979 in three Private counties. Arhus county has no or­ pathologists ganized screening programme and the majority of smears are taken by GPs on Private clinical indication. Frederiksborg coun­ gynecologists ty has an organized programme based on mailed pipettes, and table 3 shows that the number of pipettes is almost equivalent to the number of smears CPs in taken by GPs. The total screening activ­ organized ity in Frederiksborg county in was 1979 programmes two times the total activity in Arhus county; 0.60 and 0.30 smears per year per woman, respectively. In Storstnllm county an organized programme was Women Hospital based on smears taken by GPs, and the themselves dept's of number of smears taken in the program­ in org. prog. pathology me was equivalent to the number of smears taken by GPs on clinical indica­ tion. Despite the existence of an or­ Hospital ganized programme the total activity in departments Storstr0m county was equivalent to the total activity in Arhus county; table 3 shows that this is mainly due to a low Huisarts en Wetenschap 1984; 27 413 number of smears taken by GPs on this is a demand for limitation of health cytology is recommended within 6-12 clinical indication. care expenditures coordination of the months. The data consequently indicate that in smear-taking activity has been taken up • In women at high risk, for instance the areas where there is an organized by several counties in order to restrict very early onset of sexual life, several screening programme based on smears the number of repeated smears. Coordi­ coital partners, or partners with several taken by GPs, the GPs tend to restrict nation is depending on a sufficient coital partners, prophylactic cytologies the number of smears taken on clinical capacity in the departments of patholo­ are recommended to be performed with indication, whereas this is not the case in gy which is still not available in all the same intervals as mentioned above, areas with organized programme based counties.
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