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A Longitudinal Swedish Study on Screening for Squamous Cell Carcinoma and Adenocarcinoma: Evidence of Effectiveness and Overtreatment

¹ Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; ² Division of Clinical Cancer epidemiology, Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden; and ³ Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts

Requests for reprints: Anthony S. Gunnell, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, P.O. Box 281, 171 77 Stockholm, Sweden. Phone: 468-524-86131; Fax: 468-314975. E-mail: anthony.gunnell{at}ki.se

Background: Organized Papanicolaou (Pap) screening has markedly reduced the incidence of cervical squamous cell carcinoma (SCC). However, the potential for overtreatment of precursor lesions is quite high for SCC, and the effectiveness of Pap screening for prevention of cervical adenocarcinoma is questionable.

Methods: Using the nationwide, virtually complete Swedish Cancer Register, we analyzed standardized incidence rates for SCC in situ (CIS), SCC, adenocarcinoma in situ (AIS) and adenocarcinoma, between 1968 and 2002. For each county, we calculated Spearman correlations between incidence of in situ lesions and incidence of invasive cancer, 5, 10, and 15 years later. We also used generalized estimating equation (GEE) models to compare adjusted estimates for associations between in situ incidences and invasive carcinomas over counties.

Results: The overall decrease in SCC incidence in Sweden following the introduction of cervical screening confirms the beneficial nature of cervical screening on SCC incidence over the last 30 years. A similar benefit was not apparent for adenocarcinoma. GEE estimates for the relative change in SCC for an increase of 100 CIS cases per 100,000 women-years were 1.05 for the 5-year and 1.02 for the 10-year lag periods. For adenocarcinoma and AIS, similar analyses gave corresponding estimates of 1.17 for the 5-year and 1.08 for the 10-year lag periods. The lack of an inverse correlation suggests that increased reported incidence of CIS in certain counties did not forecast a reduction in SCC for those counties.

Conclusion: Our data confirm the effectiveness of Pap smear screening in reducing the incidence of SCC, but suggest no clear benefit on adenocarcinoma. Our data also suggest that relaxed histopathologic criteria for diagnosis of cervical CIS may increase its recorded incidence with no measurable benefit in the reduction of invasive cancer. (Cancer Epidemiol Biomarkers Prev 2007;16(12):2641–8)

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