Benefits and challenges of cervical cancer screening since the implementation of the 'two cancer' screening programme in China: findings from Shangyu, Zhejiang in 2019-23.

Background: Cervical cancer is the fourth most common cancer in women worldwide. The World Health Organization has long targeted its elimination and stressed the need for enhanced screening coverage and improved treatment rates. The Chinese government initiated the 'two cancer' screening programme for cervical and breast cancer in 2009 for women aged 35-64 years, which Shangyu fully implemented in 2017. We evaluated the programme's progress in Shangyu using data from 2019-23, aiming to suggest feasible improvements and provide general recommendations for regions facing similar challenges.

Methods: We used data collected and shared by the Shaoxing Shangyu Maternal and Child Health Hospital from 2019 to 2023. The study sample included 59 201 unemployed women aged 35-64 residing in Shangyu, Shaoxing with no previous cervical cancer histories. Following international guidance, we sent their cervical samples for HPV genotyping and liquid cytology testing and asked them to receive colposcopy as needed for eventual diagnosis, which was subsequently categorised into normal, low-grade cervical intraepithelial neoplasia (CIN 1), high-grade cervical intraepithelial neoplasia (CIN 2-3), squamous cell carcinoma (SCC), adenocarcinoma in situ (AIS), and adenocarcinoma (AA). We used logistic regressions to investigate potential associations between participants' demographic characteristics, risks of HPV positivity, and eventual diagnosis.

Results: The prevalence of HPV was 11.65% between 2019 and 2023. The three most common subtypes were HPV-52, HPV-16, and HPV-59. Among those who tested positive and received colposcopy, 97.05% had a normal diagnosis, 1.68% had CIN 1, 0.64% had CIN 2-3, 5.74‱ had SCC, 0.68‱ had AIS, and 0.51‱ had AA. Participants aged 50-54 years (adjusted odds ratio (aOR) = 1.19; 95% confidence interval (CI) = 1.02-1.38), 60-64 years (aOR = 1.33; 95% CI = 1.13-1.57), and those who took birth control pills alone (aOR = 2.35; 95% CI = 1.24-4.46) were associated with an increased likelihood of being tested HPV-positive. Older ages, specifically 55-59 years (aOR = 0.53; 95% CI = 0.29-0.96) and 60-64 years (aOR = 0.46; 95% CI = 0.25-0.85), were associated with a decreased likelihood of developing CIN 2-3. Contraceptive use of intrauterine devices alone was associated with an increased likelihood of developing CIN 2-3 (aOR = 1.41; 95% CI = 1.00-1.99). Being in menopause was associated with a decreased likelihood of developing SCC (aOR = 0.2; 95% CI = 0.06-0.65).

Conclusions: As the pilot city of the 'two cancer' screening programme, Shangyu saw a gradual yearly increase in cervical cancer screening coverage. However, lack of awareness, reluctance to receive screening and later colposcopy, and underutilisation of screening alternatives undermined further progress. Future medical services and policies should prioritise health education and target neglected groups in both rural and urban areas.