Kohdunkaulasyövän seulonnan arviointi

The aim of this study was to evaluate the performance and age-specific effectiveness of cervical cancer screening, by focusing on audit studies of the Finnish cervical cancer screening programme within case control designs with information on the outcome of screening. The study also developed further quality assurance protocols for integration into the programme. The coverage and accuracy of diagnostic data in the screening register were evaluated via individual linkage to two other health care registers. Precancerous and cancerous lesions arising in the screened population were used in an audit of cytology wherein screening-test validity in programme service laboratories was evaluated with a focus on sensitivity failures in the form of false negative screening results. Outcome measures were also related to cross-sectional performance indicators, and variations between laboratories were explored. The mode of detection and screening history was determined for every cervical cancer case and cervical cancer death in Finland in 2000 - 2009. Population-based controls were used in estimation of the age-specific effectiveness of the organised programme in a case control design. We were also able to perform age-specific self-selection bias corrections of the effectiveness estimates. The quality of the screening and cancer registers is such that reliable monitoring and also individual case audits are possible. We found that some analytical failures as measured in terms of false-negative rates of case smears do occur in the programme but that their impact on cancer incidence is small. However, the reproducibility of the cytodiagnosis and variations in the specificity of the screening laboratories should be addressed by means of cytology audits and feedback to the screeners. A large proportion of the cervical cancers and most deaths from cervical cancer occur at ages above the currently recommended invitational ages. Only a very small proportion of the burden arises before first invitation. Non-attenders contribute significantly to incidence and mortality, and a smaller proportion of cases can be attributed to screening failures. Management of screening positives appears to be excellent. The effectiveness of screening, as measured by the reduction in the risk of cervical cancer and death from cervical cancer associated with participation in organised screening, was strongly dependent on age. Screening at ages below 40 and, especially, below 30 was associated with a clearly smaller risk reduction than screening at 40 and above. Also the duration of the protective effect was age-dependent. Most cancers and cancer deaths currently occur because of a lack of screening, and not because of low quality of the screening test or management process. Monitoring and audits of the screening programme are clearly important for the programme s development and further optimisation.Tämän väitöskirjatyön tavoitteena oli tutkia kohdunkaulan syöpää ehkäisevän seulonnan diagnostinen laatu ja ikäspesifi vaikuttavuus. Tutkimus paneutui Suomen seulontaohjelmassa tapaus-verrokki -asetelmissa tehtyihin audititointitutkimuksiin, joissa seulonnan päätetapahtumista saatavilla oleva informaatio otettiin huomioon. Seulontarekisterin seulontalöydöstiedon laatu arvioitiin yhdistämällä tietoja kolmesta eri terveydenhuoltoon liittyvästä rekisteristä. Sytologisen seulontatestin osuvuutta arvioitiin erityisesti väärien negatiivisten osalta. Suomen 2000-luvun syöpätapahtumien diagnoositapa ja seulontahistoria määritettiin yhdistämällä syöpärekisterin kattavat syöpätiedot seulontarekisterin tietoihin. Väestöpohjaisten verrokkien avulla arvioitiin seulontatestin ikäryhmäkohtaista vaikuttavuutta ilmaantuvuuteen ja kuolleisuuteen. Seulonta- ja syöpärekisteritiedon laatu on korkeaa tasoa ja mahdollistaa näin ollen luotettavan laadunvarmistustoiminnan ja tapausten auditoimisen. Seulontaohjelmassa tapahtuu jonkin verran analyysivirheitä mutta näiden vaikutus syövän ilmaantuvuuteen on pieni. Sytologisen diagnoosin toistettavuus ja laboratoriokohtaisen testitarkkuuden vaihtelut kuitenkin vaativat prosessin tarkkailua, palautteen antamista ja toiminnan kehittämistä myös jatkossa. Suuri osa kohdunkaulan syövistä ja suurin osa kuolemista ajoittuvat diagnoosiltaan seulontaohjelman viimeisen kutsun jälkeiseen aikaan naisen elämässä. Tämä kuvastaa osaltaan seulontaikäryhmiin kohdistuvan seulonnan vaikuttavuutta koska seulomattoman väestön kohdunkaulan syövästä aiheutuva taakka ajoittuu paljon nuorempaan väestöön. Toisaalta vain hyvin pieni osa syövistä diagnosoidaan ennen ensimmäistä seulontakutsua. Seulontaan osallistumattomat naiset muodostavat toiseksi suurimman joukon ja pienempi osa kohdunkaulan syövistä ja kuolemista kohdistuu seulontaan osallistuneiden joukkoon. Positiivisten seulontalöydösten hoidon ja seurannan laatu vaikuttaa erinomaiselta. Seulontaan osallistumisen ja päätetapahtumien riskin välinen yhteys oli ikäriippuvainen, siten että alle 40 vuoden, ja etenkin alle 30 vuoden iässä tapahtuvalla ohjelmaseulonnalla arvioitiin olevan selvästi pienempi vaikutus kuin 40:n ja sitä vanhempien seulonnalla. Tutkimustulosten valossa voidaan todeta että suurin osa kohdunkaulan syövistä ja niihin liittyvistä kuolemista johtuvat naisen seulomattomuudesta, eikä niinkään seulonnan laadun puutteista. Laboratoriotoiminnan ja etenkin seulontatestin tarkkuuden vaihtelut kuitenkin vaativat palautejärjestelmää jotta toiminta voitaisiin yhdenmukaistaa ja vääristä positiivisista testivastauksista johtuvat haittavaikutukset minimoida. Seulontaohjelman vaikuttavuuden ylläpitäminen ja edelleen kehittäminen vaatii laadunvarmistustoimintaa ja syöpätapausten auditointitutkimuksia myös jatkossa

Cervical cancer in women under 30 years of age in Norway: a population-based cohort study

Background We compared women with incident cervical cancer under the age of 30 with older women with regard to stage, morphology, screening history and cervical cancer mortality in a population-based cohort study. Methods We included data from the Cancer Registry of Norway. Incidence rates (per 100,000 women-years) were calculated and joinpoint regression was used to analyse trends. The Nelson-Aalen cumulative hazard function for risk of cervical cancer death during a 15-year follow-up was displayed. The hazard ratios (HRs) of cervical cancer mortality with 95% confidence intervals (CIs) were derived from Cox regression models. Results The incidence of cervical cancer in women under the age of 30 has almost tripled since the 1950s, with the steepest increase during 1955–80 (with an annual percentage change (APC) of 7.1% (95%CI 4.4–9.8)) and also an increase after 2004 (3.8% (95%CI -1.3–9.2)). Out of 21,160 women with cervical cancer (1953–2013), 5.3% were younger than 30 years. A lower proportion of younger women were diagnosed at more advanced stages and a slightly higher proportion were diagnosed with adenocarcinoma and adenosquamous carcinoma comparing women above 30 years. The cumulative risk of cervical cancer death was lower for patients under the age of 30. However, the difference between the age groups decreased over time. The overall adjusted HR of cervical cancer mortality was 0.69 (95% CI 0.58–0.82) in women diagnosed under the age of 30 compared to older women. Conclusion There has been an increase in cervical cancer incidence in women under the age of 30. Cervical cancer in younger women was not more advanced at diagnosis compared to older women, and the cervical cancer mortality was lower.publishedVersio

Elpistolens vara eller inte vara inom den svenska polisen

Vi vill genom vårt arbete belysa vad elpistolen har för fördelar och nackdelar och vad effekterna skulle kunna bli om den skulle börja användas av svensk polis. Under 2005 planerades ett fältförsök med elpistolen men innan det hann ske stoppades försöket av polisens etiska råd. Elpistolen var fram till dess ett första val bland olika icke dödliga hjälpmedel, ett självklart redskap för att täcka upp glappet mellan batong/pepparspray och tjänstevapnet Sig-Sauer. Elpistolen som polisen tagit fram för fältförsöket var av modell X-26, ett pistolliknande redskap som skjuter två hullingar som fäster i hur och kläder. Vid träff levererar den 50 000 volt in i kroppen, elektriciteten gör så att kroppens muskler krampar ihop. Den polisman som har drivit på det planerade fältförsöket intervjuades per telefon. Dessutom har mailkontakt förekommit. Kontakt med FOI gällande den medicinska biten har tagits. Det som går att fastställa är att det etiska rådet på egen hand blåste av fältförsöket som planerades. De presenterade en rapport som visar att svensk polis inte är i behov av någon elpistol. Etiska rådet menade på flera punkter att försöket var ett förhastat beslut. Etiska rådet var de enda som beslutade att de planerade fältförsöken av elpistolen skulle avbrytas. Elpistolen är ett bra vapen med god effekt som kan rädda liv och undvika skador men har vissa nackdelar som t.ex. det höga priset. Om elpistolen skulle införas i Sverige så tror vi inte det skulle bli någon stor skillnad på hur allmänheten uppfattar polisen

Kostnader ved Masseundersøkelsen mot livmorhalskreft

Bakgrunn: Forebygging står sentralt i norsk helsepolitikk, og observasjonsstudier tyder på at organisert screening har redusert forekomsten av livmorhalskreft i Norge. Samfunnets ressurser er imidlertid knappe. Hensikt: Vår hensikt var å estimere de årlige kostnadene av Masseundersøkelsen mot livmorhalskreft. Metode: Vi beregnet statens direkte utgifter og de årlige samfunnsøkonomiske kostnader av dagens screeningprogram for livmorhalskreft på grunnlag av opplysninger fra Kreftregisteret om antall utførte undersøkelser under Masseundersøkelsen for livmorhalskreft og enhetskostnadene for disse. De samfunnsøkonomiske enhetskostnadene er basert på ulike beregninger av faktiske kostnader, mens statens utgifter er basert på de ulike takstsystemer. Resultater: I 2011 ble det utført i alt 360 704 primærscreeningprøver, som med våre beregninger ville medføre 21 783 nye etterundersøkelser. Det ble innsendt biopsier for omtrent 9000 kvinner, og 3057 kvinner fikk utført konisering. De samlete samfunnsøkonomiske kostnader ved screeningprogrammet var 730 millioner kroner, hvorav 52 prosent utgjorde indirekte kostnader i form av reisekostnader og fravær fra arbeid. Statens direkte utgifter utgjorde 163 millioner kroner. Konklusjon: Det norske screeningprogrammet for livmorhalskreft har betydelige kostnader, der kvinnenes tids- og reisekostnader og legekonsultasjoner veier mest

Setting the record straight—Correcting uterine cancer incidence and mortality in the Nordic countries by reallocation of unspecified cases

Introduction: The incidence of and mortality from cancers of the cervix uteri and corpus uteri are underestimated if the presence of uterine cancers, where the exact topography (site of origin) is not specified, is omitted. In this paper we present the corrected figures on mortality from and incidence of cervix and corpus uteri cancers in the Nordic countries by reallocating unspecified uterine cancer deaths and cases to originate either from the corpus uteri or cervix uteri. To further validate the accuracy of reallocation, we also analyzed how well the reallocation captures the changes occurring as the result of a transition in cause of death coding in Norway that took place in 2005. Material and Methods: This study uses data available in the NORDCAN database, which contains aggregated cancer data from all the Nordic countries for the years 1960–2016. The unspecified uterine cancer cases and deaths were reallocated to either cervix uteri or corpus uteri based on the estimated probability that follows the distribution of cases and deaths with verified topography. The estimated proportions of cases and deaths for both cancers were calculated for each combination of age group, year, and country as a proportion of cases (and deaths, respectively) with known topography. Annual age-standardized rates were calculated by direct age-adjustment. Results: The proportions of unspecified uterine cancers were higher in the mortality data than in incidence data, with mean values for 1960–2016 ranging between 5.1% and 26.6% and between 0.2% and 6.8% by country, respectively. In the Nordic countries combined, the reallocation increased the number of cases by 4% and deaths by approximately 20% for both cancers. Finland was the only Nordic country where the mortality rate did not increase substantially after reallocation. Conclusions: The reallocation procedure had a significant impact on mortality from cancers of the cervix and corpus uteri for countries where the proportion of cancer deaths coded as uterus, not otherwise specified, is substantial. More effort to validate cause of death data with incidence data from cancer registries is warranted to avoid erroneous conclusions of temporal trends based on uncorrected cancer burden.publishedVersionPeer reviewe

Cervical cancer in women under 30 years of age in Norway: a population-based cohort study

Background We compared women with incident cervical cancer under the age of 30 with older women with regard to stage, morphology, screening history and cervical cancer mortality in a population-based cohort study. Methods We included data from the Cancer Registry of Norway. Incidence rates (per 100,000 women-years) were calculated and joinpoint regression was used to analyse trends. The Nelson-Aalen cumulative hazard function for risk of cervical cancer death during a 15-year follow-up was displayed. The hazard ratios (HRs) of cervical cancer mortality with 95% confidence intervals (CIs) were derived from Cox regression models. Results The incidence of cervical cancer in women under the age of 30 has almost tripled since the 1950s, with the steepest increase during 1955–80 (with an annual percentage change (APC) of 7.1% (95%CI 4.4–9.8)) and also an increase after 2004 (3.8% (95%CI -1.3–9.2)). Out of 21,160 women with cervical cancer (1953–2013), 5.3% were younger than 30 years. A lower proportion of younger women were diagnosed at more advanced stages and a slightly higher proportion were diagnosed with adenocarcinoma and adenosquamous carcinoma comparing women above 30 years. The cumulative risk of cervical cancer death was lower for patients under the age of 30. However, the difference between the age groups decreased over time. The overall adjusted HR of cervical cancer mortality was 0.69 (95% CI 0.58–0.82) in women diagnosed under the age of 30 compared to older women. Conclusion There has been an increase in cervical cancer incidence in women under the age of 30. Cervical cancer in younger women was not more advanced at diagnosis compared to older women, and the cervical cancer mortality was lower