Cervical Screening Participation | Description of Indicator | Age-adjusted percentage of Ontario screen-eligible women, 21-69 years old, who completed at least one Pap test in a 42-month period | | Figures/Graphs | Figures 1 and 2 | | Rationale for Measurement | Cervical cancer screening using cervical cytology (Pap smear) can lead to early detection of pre-cancerous lesions before they develop into invasive cervical cancer, thereby reducing both cervical cancer incidence and mortality. (1–3) Adequate participation in cervical cancer screening is essential for reductions in mortality to occur in the Ontario population. (4) Participation is one of the most important factors in determining the success of an organized screening program. (5) | | Evidence/References for Rationale | - Andrae B, Kemetli L, Sparen P, Silfverdal L, Strander B, Ryd W, et al. Screening-preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer Inst. 2008;100(9):622-9.
- Laara E, Day NE, Hakama M. Trends in mortality from cervical cancer in the Nordic countries: Association with organized screening. Lancet. 1987 May 30;1(8544):1247–9.
- Walsh JM. Cervical cancer: Developments in screening and evaluation of the abnormal Pap smear. West J Med. 1998 Nov;169(5):304–10.
- International Agency for Research on Cancer Prevention; World Health Organization. Handbook of cancer screening volume seven: cervix cancer screening. Lyon: IARCPress; 2005.
- Hakama M. Screening for cervical cancer: Experience of the Nordic countries. In: Franco E., Monsonego J., editors. New developments in cervical cancer screening and prevention. Oxford [England]; Malden, MA, USA: Blackwell Science; 1997. p. 190–99.
| | Calculations for the Indicator | (Total number of Ontario screen-eligible women, 21-69 years old, who have completed at least one Pap test in a 42-month period/ Total number of Ontario screen-eligible women, 21-69 years old, in the reporting period) x 100 = Participation | | Standardized Rate Calculation | 2011 Canadian population | | Unit | Percentage (%) | | Data Sources | - CytoBase - Pap tests
- OHIP's CHDB (Claims History Database) – Pap tests, hysterectomy claims
- OCR (Ontario Cancer Registry) - Resolved invasive cervical cancers
- RPDB (Registered Persons Database) - Demographics
- PCCF+, version 6C- Residence and socio-demographic information
| | Time Frame | 2001-2015 | | Geographic Scale | - Provincial (Ontario)
- LHIN of residence
| | Denominator Description | Total number of Ontario screen-eligible women, 21-69 years old, in the reporting period - Ontario screen-eligible women age 21-69 at the index date
- Index date was defined as the midpoint in a reporting period, e.g. July 1st 2014 for 2013-2015
- The 2011 Canadian population was used as the standard population for calculating age-standardized rates
- The RPDB address closest to the index date was used to assign postal code
- LHIN assignment was determined using PCCF+, version 6C; residential postal code was used to identify LHIN and individuals with unknown/missing LHINs were excluded from the analysis
- Public health unit data was determined using PCCF+, version 6C
Exclusions: - Women with a missing or invalid HIN, date of birth, LHIN or postal code
- Women diagnosed with an invasive cervical cancer prior to January 1st of the reporting period, e.g. January 1st 2013 for 2013-2015; prior diagnosis of cervical cancer was defined as: ICD-O-3 codes C53, a morphology indicative of cervical cancer, microscopically confirmed with a path report
- Women who had a colposcopy and/or treatment within 2 years prior to January 1st of the reporting period Colposcopy and/or treatment were identified through OHIP, using the following fee
- Codes:
- Colposcopy
- Z731 - Initial investigation of abnormal cytology of vulva and/or vagina or cervix under colposcopic technique with or without biopsy(ies) and/or endocervical curetting
- Z787 - Follow-up colposcopy with biopsy(ies) with or without endocervical curetting
- Z730 - Follow-up colposcopy without biopsy with or without endocervical curetting
- Treatment
- Z732 - Cryotherapy
- Z724 - Electro
- Z766 - Electrosurgical Excision Procedure (LEEP)
- S744 - Cervix - cone biopsy - any technique, with or without D&C
- Z720 - Cervix Biopsy - with or without fulguration
- Z729 - Cryoconization, electroconization or CO2 laser therapy with or without curettage for premalignant lesion (dysplasia or carcinoma in-situ), out-patient procedure
- Women with a hysterectomy prior to January 1st of the reporting period
- Women with a hysterectomy were identified through OHIP, using the following fee codes:
- E862A – When hysterectomy is performed laparoscopically, or with laparoscopic assistance
- P042A – Obstetrics – labour – delivery – caesarean section including hysterectomy
- Q140A – Exclusion code for enrolled female patients aged 35-70 with hysterectomy
- S710A – Hysterectomy - with or without adnexa (unless otherwise specified) – with omentectomy for malignancy
- S727A – Ovarian debulking for stage 2C, 3B or 4 ovarian cancer and may include hysterectomy
- S757A – Hysterectomy – with or without adnexa (unless otherwise specified) – abdominal – total or subtotal
- S758A – Hysterectomy - with or without adnexa (unless otherwise specified) – with anterior and posterior vaginal repair and including enterocoele and/or vault prolapse repair when rendered
- S759A - Hysterectomy - with or without adnexa (unless otherwise specified) – with anterior or posterior vaginal repair and including enterocoele and/or vault prolapse repair when rendered o S762A - Hysterectomy - with or without adnexa (unless otherwise specified) – radical trachelectomy - excluding node dissection
- S763A - Hysterectomy - with or without adnexa (unless otherwise specified) – radical (Wertheim or Schauta) - includes node dissection
- S765A – Amputation of cervix
- S766A- Cervix uteri - Exc - cervical stump – abdominal
- S767A- Cervix uteri - exc - Cervical stump – vaginal
- S816A - Hysterectomy - with or without adnexa (unless otherwise specified) - vaginal
| | Numerator Description | Total number of Ontario screen-eligible women, 21-69 years old, who have completed at least one Pap test in a 42 month period - Identifying Pap tests:
- Pap tests were identified through CytoBase
- Pap tests were also identified using fee codes through OHIP:
- E430A: add-on to a003, a004, a005, a006 when pap performed outside hospital
- G365A: Periodic-pap smear
- E431A: When Papanicolaou smear is performed outside of hospital, to G394.
- G394A: Additional for follow-up of abnormal or inadequate smears
- L713A: Lab.med.-anat path,hist,cyt-cytol-gynaecological specimen
- L733A: Cervicovaginal specimen (monolayer cell methodology)
- L812A: Cervical vaginal specimens including all types of cellular abnormality, assessment of flora, and/or cytohormonal evaluation
- Q678A: Gynaecology – pap smear – periodic – nurse practitioners
- L643A: Lab Med - Microbiol - Microscopy - Smear Only, Gram/Pap Stain
- All Pap tests in CytoBase were counted, including those with inadequate specimens
- Each woman was counted once regardless of the number of Pap tests performed in a 42 month time frame
| | Considerations | None | | Data Availability & Limitations | - Pap test results are available in Cytobase only
- Cytobase includes only Pap tests analyzed in community-based laboratories in Ontario; Pap tests analyzed in Ontario hospitals and Community Health Centres are not captured in CytoBase
- It is difficult to determine whether a Pap test in Cytobase/OHIP was done for screening or diagnostic purposes, and therefore, some Pap tests included in these analyses may have been performed for diagnostic purposes
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Cervical Screening Retention | Description of Indicator | Percentage of Ontario screen-eligible women, 21-66 years old, who had a subsequent Pap test within 42 months of a normal Pap test result | | Figures/Graphs | Figures 3 and 4 | | Rationale for Measurement | Cervical cancer screening using cervical cytology (Pap smear) can lead to early detection of pre-cancerous lesions before they develop into invasive cervical cancer, thereby reducing both cervical cancer incidence and mortality.1
Retention reflects the ability of women to screen repeatedly over time, as well as the acceptability of the screening test.2 Adequate retention in cervical cancer screening is essential for reductions in mortality to occur in the Ontario population.3 | | Evidence/References for Rationale | - Andrae B, Kemetli L, Sparen P, Silfverdal L, Strander B, Ryd W, et al. Screening-preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer Inst. 2008;100(9):622-9.
- Canadian Partnership Against Cancer. Cervical cancer screening in Canada: Monitoring program performance 2009–2011. Toronto: Canadian Partnership Against Cancer; 2013.
- International Agency for Research on Cancer Prevention; World Health Organization. Handbook of cancer screening volume seven: cervix cancer screening. Lyon: IARCPress; 2005.
| | Calculations for the Indicator | (Total number of Ontario screen-eligible women, 21-66 years old, who had a subsequent Pap test within 42 months of a previous normal Pap test result in a given year/ Total number of Ontario screen-eligible women, 21-66 years old, who had a normal Pap test in a given year) x100= Retention | | Standardized Rate Calculation | N/A | | Unit | Percentage (%) | | Data Sources | - CytoBase - Pap tests
- OHIP's CHDB (Claims History Database) – Hysterectomy claims
- OCR (Ontario Cancer Registry) - Resolved invasive cervical cancers
- RPDB (Registered Persons Database) - Demographics
- PCCF+, version 6C - Residence and socio-demographic information
| | Time Frame | 2008-2012 | | Geographic Scale | - Provincial (Ontario)
- LHIN of residence
| | Denominator Description | Total number of Ontario screen-eligible women, 21-66 years old, who had a normal Pap test in a given year - Ontario screen-eligible women 21-66 years old at the index date who had a normal Pap test result in a given year
- Index date was defined as the last normal Pap test date per person by date of specimen collection in CytoBase in a given year
- The RPDB address closest to the index date was used to assign postal code
- Normal Pap tests were defined through CytoBase as NILM (CytoBase codes 4.1, 4.2, 4.3.1, 4.3.2, 4.3 for version 2, and Cytobase codes 4.1, 4.2, 4.3 for version 1)
- Each woman was counted once in a given year regardless of the number of tests performed
- LHIN assignment was determined using PCCF+, version 6C; residential postal code was used to identify LHIN and individuals with unknown/missing LHINs were excluded from the analysis
Exclusions: - Women with a missing or invalid HIN, date of birth, LHIN or postal code
- Women who died during the follow-up period
- Women diagnosed with an invasive cervical cancer before the subsequent Pap date or during the follow-up interval (for cases where there was no subsequent Pap); diagnosis of cervical cancer was defined as: ICD-O-3 codes C53, a morphology indicative of cervical cancer, microscopically confirmed with a path report
- Women with a hysterectomy before the subsequent Pap date or during the follow-up interval (for cases where there was no subsequent Pap)
- Women with a hysterectomy were identified through CHDB, using the following fee codes:
- E862A – When hysterectomy is performed laparoscopically, or with laparoscopic assistance
- P042A – Obstetrics – labour – delivery – caesarean section including hysterectomy
- Q140A – Exclusion code for enrolled female patients aged 35-70 with hysterectomy
- S710A – Hysterectomy - with or without adnexa (unless otherwise specified) – with omentectomy for malignancy
- S727A – Ovarian debulking for stage 2C, 3B or 4 ovarian cancer and may include hysterectomy
- S757A – Hysterectomy – with or without adnexa (unless otherwise specified) – abdominal – total or subtotal
- S758A – Hysterectomy - with or without adnexa (unless otherwise specified) – with anterior and posterior vaginal repair and including enterocoele and/or vault prolapse repair when rendered
- S759A - Hysterectomy - with or without adnexa (unless otherwise specified) – with anterior or posterior vaginal repair and including enterocoele and/or vault prolapse repair when rendered
- S762A - Hysterectomy - with or without adnexa (unless otherwise specified) – radical trachelectomy - excluding node dissection
- S763A - Hysterectomy - with or without adnexa (unless otherwise specified) – radical (Wertheim or Schauta) - includes node dissection
- S765A – Amputation of cervix
- S766A- Cervix uteri - Exc - cervical stump – abdominal
- S767A- Cervix uteri - exc - Cervical stump – vaginal
- S816A - Hysterectomy - with or without adnexa (unless otherwise specified) - vaginal
| | Numerator Description | Total number of Ontario screen-eligible women, 21-66 years old, who had a subsequent Pap test within 42 months of a previous normal Pap test result in a given year - Subsequent Pap tests were identified through CytoBase
- All tests were considered, regardless of test result
| | Considerations | None | | Data Availability & Limitations | - Only CytoBase data was used for these analyses as there were no results for OHIP data
- CytoBase data is limited to community-based laboratories
- Some women with a scheduled Pap test (follow-up) may be included in this cohort
- It is difficult to determine whether a Pap test was done for screening or diagnostic purposes; a small proportion of tests included in our analyses may have been performed for diagnostic purposes
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