|Measure ||Desired Direction||As of this Report |
|Participation: Percentage of Ontario screen-eligible women, ages 21 to 69, who completed at least 1 Pap test in a 42-month period|
|Retention: Percentage of Ontario screen-eligible women, ages 21 to 66, who had a subsequent Pap test within 42 months of a normal Pap test result|
| See Methodology and Approach to find out how the ratings are calculated. |
In 2012–2014, approximately 2.8 million Ontario women aged 21 to 69 were screened for cervical cancer with a Pap test (63% of eligible women). Participation in cervical screening decreased by 5 percentage points between 2009–2011 and 2012–2014 (from 68% in 2009–2011 to 63% in 2012–2014). In 2003–2005, participation was at 66%.
The number of women who meet eligibility criteria for screening through the Ontario Cervical Screening Program (OCSP) has continued to increase, from 3.8 million women in 2003–2005 to 4.4 million women in 2012–2014.
Seventy-two percent of Ontario women who had a normal Pap test result in 2011 returned for another Pap test within 42 months. In 2008, 85% of the women who had a normal Pap that year returned for a subsequent Pap test within 42 months; a difference of 13 percentage points.
It is important to note that Cancer Care Ontario updated its cervical cancer screening guidelines in 2012. Between 2008 and 2011, Cancer Care Ontario recommended women return for screening in 12 months. Women screened in 2008 would be expected to be rescreened in 2009, 2010 and 2011, a total of 3 screenings in the 42 month-period following their 2008 Pap test. From 2012 onward, Cancer Care Ontario recommended women return from screening in 36 months. Women screened in 2011 would be expected to be rescreened in 2014, a total of 1 screening in the 42 month-period following their 2011 Pap test. The probability that women would be rescreened within 42 months may be influenced by the screening interval.
What is cervical cancer screening (Pap test)?
- A screening test identifies people in a healthy, asymptomatic population who may be at risk for disease. It is not a diagnostic test. The purpose of screening is to prevent cancer by identifying pre-cancerous changes or to find cancer at an early stage, when it is easier to treat. Ontario operates screening programs for 3 types of cancer: breast, cervical and colorectal.
- The purpose of cervical screening is to prevent cervical cancer by identifying pre-cancerous changes to the cells of the cervix.
- Changes in the cervix usually develop very slowly over many years, so there is a long period of time when abnormal cell changes can be detected before cervical cancer appears. These changes, called precursor lesions, can be found with a Pap test.
- Colposcopy is a diagnostic procedure performed following an abnormal Pap test result. This procedure allows a colposcopist to selectively take tissue samples of cervical abnormalities so a pathologist can make a definitive diagnosis and a doctor can develop a treatment plan1.
- After the diagnostic process is complete, a woman requiring treatment could undergo a loop electrical excision procedure, laser therapy, cryotherapy or cold knife cone biopsy1. Treating precursor lesions is intended to prevent cervical cancer from developing.
- Cancer Care Ontario updated its cervical cancer screening guidelines in 2012. It now recommends cervical cancer screening every 3 years for women aged 21 to 69 who are, or who have ever been, sexually active. Screening can stop at 70 years of age in women who have had 3 or more normal tests within the previous 10 years2.
What do the results show?
Cervical cancer screening participation declined in 2012–2014 (Figure 1).
- Provincial cervical cancer screening participation in 2012–2014 (63%) was lower than in 2009–2011 (68%) and falls short of the 85% target.
- Approximately 2.8 million Ontario women aged 21 to 69 were screened for cervical cancer in 2012–2014.
- In 2012–2014, the Local Health Integration Network (LHIN) with the highest participation was Champlain (67%). The Toronto Central LHIN had the lowest participation (59%) over the same period.
Cervical cancer screening participation varies by socio-demographic factor‡.
- In 2012–2014, cervical cancer screening participation varied by age group (Figure 2). Participation was highest among women aged 30 to 39 (68%), and lowest among women aged 60 to 69 (53%). Participation declined in all age groups between 2009–2011 and 2012–2014.
- In 2012–2014, participation was highest (66%) in rural areas and lowest in rural-very remote areas (61%).
- Participation increased steadily as urban neighbourhood income rose. In 2012–2014, participation was highest (68%) among eligible women living in the highest income urban areas, compared to 57% among eligible women living in the lowest income urban areas, a difference of 11 percentage points.
- Participation decreased as the percentage of self-reported immigrant residents in a neighbourhood increased. In 2012–2014, 66% of eligible women living in neighbourhoods with the lowest concentration of self-reported immigrant residents participated in cervical cancer screening, compared to 59% of eligible women in neighbourhoods with the highest concentrations of self-reported immigrant residents.
‡ Percentages by socio-demographic factor are available in the data tables (select the desired file type and click “Download”) and presented in the figures by age group.
Cervical cancer screening retention needs improvement (Figure 3).
- Approximately 912,472 women who had a normal Pap test in 2011 returned for a subsequent Pap test within 42 months (equivalent to 72% of eligible women). This is a decline of 8 percentage points from the previous screening cohort (women who had a normal Pap test in 2010), when 80% returned for a subsequent Pap test within 42 months.
- Retention has declined for each cohort of women. For example, retention among women who had a normal Pap test in 2008 was 85%, compared to 72% for women who had a normal Pap test in 2011.
- Among women who had a normal Pap in 2011, the Central LHIN had the highest retention (75%). The North East and North West LHINs had the lowest retention (66%). Retention declined in all LHINs for the most recent cohort of women (those who had a normal Pap test in 2011).
Cervical cancer screening retention varies by socio-demographic factor‡.
- Cervical cancer screening retention varied by age group (Figure 4). Looking only at the most recent data (women who had a normal Pap in 2011 and who returned for a subsequent Pap test within 42 months), retention was highest (73%) in the youngest age group: women ages 21 to 29. Retention was lowest, at 68%, in the oldest age group: women ages 60 to 66. A similar trend can be seen in earlier cohorts.
- For the cohort of women who had a normal Pap test in 2011, retention was lowest in rural-remote areas (66%) and increased closer to urban centres; retention was highest (72%) in urban areas.
- Retention among women who had a normal Pap test in 2011 increased steadily as urban neighbourhood income quintiles rose. Among women living in the lowest income urban neighbourhoods, 68% returned for a subsequent Pap test within 42 months, compared to 74% of women living in the highest income urban neighbourhoods, a difference of 6 percentage points.
‡Percentages by socio-demographic factor are available in the data tables (select the desired file type and click “Download”) and presented in the figures by age group.
Why is this important to Ontarians?
Cervical cancer screening has reduced cervical cancer incidence and mortality.
- Organized cervical cancer screening significantly reduces cervical cancer incidence (i.e. new cancer cases) and mortality (i.e. deaths)3–5. Long-term reductions in cervical cancer incidence rates and mortality in Ontario are related to regular screening with appropriate and timely follow-up.
- An estimated 640 Ontario women were diagnosed with cervical cancer in 2015 and roughly 150 women died of the disease in the same year6.
- Virtually all cervical cancers and their precursor lesions are caused by persistent infection with high-risk oncogenic (i.e. cancer-causing) human papillomavirus (HPV) types, especially types 16 and 187–9. HPV is transmitted through intimate sexual contact and is common among sexually active men and women10,11.” “Most sexually active men and women will acquire an HPV infection in their lifetime11–13. Most HPV infections will go away or clear without causing harm. Factors that determine clearance as opposed to persistence of a high-risk HPV infection are not well understood.
- Persistent high-risk HPV infections are a necessary factor in the development of cervical cancer and pre-cancerous changes in the cervix.
- Through regular screening and the appropriate and timely follow-up of abnormal results, it is possible to prevent cervical cancer from developing or to detect it early, when it is easier to treat.
Cervical cancer screening needs to continue in an era of HPV vaccination.
- Vaccines are now available to prevent infection with the major oncogenic strains of HPV that have been linked to the development of the majority of cervical cancer cases14.
- Vaccinated women should continue to be regularly screened for cervical cancer. While current vaccines target the majority of oncogenic types, other oncogenic types exist. Moreover, vaccines do not provide protection for people infected with high-risk HPV before immunization.
- Because HPV infections and pre-cancerous cervical changes rarely cause symptoms, screening is the only way to detect early changes that could lead to cervical cancer.
How does Ontario compare with other jurisdictions?
- Ensuring there is comparable data and measures from multiple jurisdictions is a challenge. It is recommended to use caution when comparing indicators from different jurisdictions due to the different data definitions, methodologies and years that are used in indicators measured outside of and across Canada. Cross-jurisdictional comparison is still useful, however, for providing a rough indication of how well Ontario is doing compared to other jurisdictions.
- Across provinces, Ontario’s participation for 2012–2014 (corrected for hysterectomies) is below that of New Brunswick (80% in 2013); however, New Brunswick’s estimate is based on self-reported data15.
- For more information on comparisons of cervical cancer screening participation between jurisdictions, see the comparison of screening section of CSQI.
- Cancer Care Ontario’s updated guidelines recommend HPV testing as the primary screening test for cervical cancer. Cancer Care Ontario continues to work with the Ministry of Health and Long-Term Care to make the HPV test the primary tool for cervical cancer screening in Ontario.
- In the interim, the OCSP supports continuing with cervical cytology as the primary screening test.
- Cancer Care Ontario has developed an online Primary Care Screening Activity Report (PC SAR) for all 3 screening programs (cervical, breast and colorectal cancer). This tool (accessed online) allows physicians in a Patient Enrolment Model (PEM) practice to see the complete screening status of each patient, including those who are due for screening and follow-up. Next steps including working with the regional primary care leads to identify barriers to adoption of the tool and to promote and encourage use of the PC SAR.
- Cancer Care Ontario is developing strategies to increase access, align processes, improve practices and enhance the quality of colposcopy services in the province.
- The OCSP correspondence program began in the fall of 2013. Women eligible to be screened for cervical cancer are mailed letters inviting them to be screened, advising them of their test results and reminding them when it is time to return for screening.
- Annual public awareness campaigns are conducted in each region.
- Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario. Insight on cancer: news and information on cervical cancer; 2005 Oct [cited 2015 Dec 18]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=13802
- Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario. Ontario cervical screening cytology guidelines summary; 2012 May [cited 2015 Dec 18]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=13104.
- Pettersson F, Björkholm E, Näslund I. Evaluation of screening for cervical cancer in Sweden: trends in incidence and mortality 1958–1980. Int J Epidemiol. 1985 Dec; 14(4):521–7.
- Lynge E, Madsen M, Engholm G. Effect of organized screening on incidence and mortality of cervical cancer in Denmark. Cancer Res. 1989 Apr 15; 49(8):2157–60.
- Quinn M, Babb P, Jones J, Allen E. Effect of screening on incidence of and mortality from cancer of the cervix in England: evaluation based on routinely collected statics. BMJ. 1999 Apr 3; 318(7188):904–8.
- Canadian Cancer Society. Canadian cancer statistics, 2015. Toronto: Canadian Cancer Society, Steering Committee on Cancer Statistics; 2015.
- Kwong J, Crowcoft N, Campitelli MA, Ratnasingham S, Daneman N, Deeks SL, et al. Ontario burden of infectious disease study (ONBOIDS). Toronto: Ontario Agency for Health Protection and Promotion, Institute for Clinical Evaluative Sciences; 2010.
- Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999 Sep; 189(1):12–9.
- Franco EL, Schlecht NF, Saslow D. The epidemiology of cervical cancer. The Cancer Journal. 2003 Oct; 9(5):348–59.
- Yabroff KR, Mandelblatt JS, Kerner JF. Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening. Prev Med. 2000 Oct; 31(4):429–39.
- Brown DR, Shew ML, Qadadri B, Neptune N, Vargas M, Tu W, et al. A longitudinal study of genital human papillomavirus infection in a cohort of closely followed adolescent women. J Infect Dis. 2005 Jan 15; 191(2):182–92.
- Koutsky L. Epidemiology of genital human papillomavirus infection. Am J Med. 1997 May 5; 102(5A):3–8.
- Bosch FX, de Sanjosé S. Human papillomavirus and cervical cancer: burden and assessment of causality. J Natl Cancer Inst Monogr. 2003; 31:3–13.
- Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R, et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. Int J Cancer. 2007 Aug 1; 121(3):621–32.
- Canadian Partnership Against Cancer. The 2015 cancer system performance report. Toronto: Canadian Partnership Against Cancer; 2015.