Each year, around 150 people are diagnosed with and 60 people die of cervical cancer in Estonia. Participation rates in the country's cervical cancer screening program, however, which could help detect cervical cell changes, precancerous conditions and cancer itself early, remain low.
Of the some 150 people diagnosed with cervical cancer each year, the average patient is between the ages of 45-60. One of the primary causes of cervical cancer is the human papillomavirus (HPV). In order to catch the virus early, women between the ages of 30-65 are invited for screening every five years, where they are tested for HPV.
As this is a preventable disease, the number of cases in Estonia is considered too high, and cancer is detected at too advanced an age. Both Estonia and Finland, for example offer the same prevention measures — vaccination against HPV and screenings — however women in Finland die of cervical cancer four times less often.
Estonian Health Insurance Fund (EHIF) board member Maivi Parv acknowledged that the low participation rate of women in Estonia's cervical cancer screening program is a problem. Last year, for example, just 44 percent of those called up to participate actually did so. "Clearly that participation rate is low, and work needs to be done on that," Parv said.
Anna Tisler, a junior research fellow of public health at the University of Tartu, has several projects underway aimed at figuring out why women aren't participating in screening programs.
Reasons for low engagement may differ by region, she noted. For example, awareness alone of the screening programs is low among women living in Ida-Viru County in Northeastern Estonia. Economic factors play a role as well.
"Not every woman can take a day off of work to go to the doctor," Tisler said. A pilot study was conducted for such women last year in which some of the women called up for screening last year were offered the novel opportunity to do their own HPV testing at home.
Low awareness of screening program
Last year, the EHIF mapped out participation in the cervical cancer screening program from both the patient and the provider's perspective. According to Parv, several bottlenecks came to light in the process, such as lack of awareness.
"We talk about how important it is to participate in the screening program, but the question is, does someone fully understand why doing so is important?" she asked. "Another factor is that people have their own fears. They will delay participating in screening as a potentially negative decision regarding their own health."
The mapping process made clear that the nature of the screening itself must be better explained to women. In order to improve their efforts, the EHIF began cooperating with behavioral researchers in order to figure out how to make changes to invitations to participate in the screening program to make them more appealing to the recipients. They determined that, going forward, the invitations should be more personal, which would encourage the recipients to continue thinking about them after reading them.
The ultimate goal, of course, is for the recipients to start looking up how they can participate.
Tisler cited that, on top of awareness, the issue of trust in Estonia's medical system shouldn't be overlooked either. In 2018, the HPV vaccine was added to the state immunization schedule for all girls in Estonia, as the vaccine is most effective prior to the recipient becoming sexually active. According to the junior research fellow, however, interest in the HPV vaccine has remained low — just one fifth of eligible girls in Estonia have been vaccinated against HPV.
She recalled previous anti-vaccine campaigns in which parents wrote to other parents to convince them not to get their children vaccinated, which she noted was an indication of a lack of trust in the medical system.
According to Tisler, another problem is that some people don't understand the concept itself of screening. People are used to addressing their health issues if and when something is wrong, or they are sick. "They know that illnesses can be treated, but they give less consideration to the fact that they can be prevented as well," she said. "We have to work on awareness of this."
Tisler is also involved in a research project, the goal of which is to develop an app that would allow women to find out right away how at risk they are personally of developing cervical cancer. Researchers working on the app are utilizing both self-reported data and data from the EHIF and the Estonian Cancer Registry in its development.
"By combining these risk factors, we want to develop an algorithm that could predict every woman's risk level," she said. "In other words, we want to personalize the screening program."
Risk factors taken into consideration include number of sexual partners, other sexually transmitted infections, but also other factors such as education level and economic situation. Women can enter additional data as well, such as whether they smoke and level of alcohol consumption. Based on the data available, the algorithm would calculate whether they specifically are at high or low risk for developing cervical cancer and recommend how often they should get tested.
Parv noted that people called up to participate in cervical cancer screening can go get tested at more than 100 different locations across Estonia, and urged anyone called up to be sure to accept the invitation as well.
"Getting screened grants you reassurance for years to come," she said.
Invited to participate in Estonia's national cervical cancer screening program this year are women born in 1957, 1962, 1967, 1972, 1977, 1982, 1987 and 1992. Participation in the screening is free both for those with and those without health insurance.
Editor: Aili Vahtla