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Screening

Six in ten Korean women who no longer have a cervix are still being screened for cervical cancer

Among women aged 30 to 44 who had a hysterectomy, the screening rate was 77.8 percent — higher than in women who still have a uterus. Meanwhile overall cervical screening has been falling since 2013, fastest in the poorest groups.

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In short

In the 2014 to 2016 Korean National Cancer Screening Survey covering 6,807 women aged 30 to 74, 61.8 percent of women who had undergone a hysterectomy had been screened for cervical cancer in the previous two years — against 64.7 percent of women with an intact uterus — and among women aged 30 to 44 those with hysterectomies were screened substantially more often than those without, 77.8 percent against 57.1 percent, despite screening not being recommended after hysterectomy in the absence of high-grade cervical disease.

Key takeaways

  • Cervical cancer screening is not recommended for women who have had a hysterectomy without a history of cervical intraepithelial neoplasia grade 2 or higher.
  • In the 2014 to 2016 Korean National Cancer Screening Survey of 6,807 women aged 30 to 74, 61.8 percent of women who had a hysterectomy had been screened in the previous two years, against 64.7 percent of women who had not.
  • Among women aged 30 to 44, those with hysterectomies were screened more often than those without: 77.8 percent against 57.1 percent.
  • Among women with a family history of cancer the same reversal appeared: 75.0 percent against 67.1 percent.
  • Overall cervical screening in Korea rose from 2005 to 2013 and has fallen since, at an annual percent change of −2.67, reaching 56.0 percent in 2020.
  • The falling trend was concentrated in women aged 40 and over, with lower education, and below middle-income level.
  • Regular participation — screening repeatedly as recommended rather than once — was 18.9 percent in a cohort of 4,663 women followed for up to 12 years.

Two things are happening to cervical screening in Korea at once, and they point in opposite directions. Women who cannot develop cervical cancer are being screened for it at close to the general rate. Women who can are being screened less each year.

Screening an organ that is no longer there

Cervical screening after a hysterectomy is not recommended for women with no history of cervical intraepithelial neoplasia of grade 2 or higher. The cervix has been removed; the test has nothing to sample. A study in BMC Cancer used the 2014 to 2016 Korean National Cancer Screening Survey to ask how often it happens anyway, across 6,807 women aged 30 to 74.

Cervical cancer screening in the previous two years, by hysterectomy status
GroupHad a hysterectomyIntact uterus
All women, 30–7461.8%64.7%
Women aged 30–4477.8%57.1%
Family history of cancer75.0%67.1%

The first row is striking enough — the two rates are almost the same. The second is stranger. Among women in their thirties and early forties, having had the organ removed was associated with being screened for its cancer more often, not less.

The rate that is falling

A separate analysis of the same national survey series, published in the Journal of Gynecologic Oncology, tracked screening rates from 2005 to 2020 using joinpoint regression. Screening rose until 2013 at an annual percent change of 2.70, then reversed, falling at 2.67 a year. By 2020 it stood at 56.0 percent.

The decline was not evenly distributed. It was significantly associated with being aged 40 or over, having education below the fifteenth grade, having household income below middle level, and it appeared across all residential areas. Women in their thirties also had a low screening rate.

18.9%

of Korean women screened for cervical cancer regularly, rather than occasionally, over up to 12 years of follow-upKim JY et al., Journal of Gynecologic Oncology, 2024

That last figure comes from a third study, which followed 4,663 women for up to twelve years and asked not whether they had ever been screened but whether they were screened regularly. Fewer than one in five were. Regularity was associated with having private insurance, with a personal or family history of gynaecological disease, and with attending general health checkups more often — the same profile that predicts most other health-service use.

What the two findings have in common

These look like separate problems and share a mechanism. Screening in Korea is largely driven by who attends checkups rather than by who is at risk. A woman engaged with the health system gets the cervical test whether or not she has a cervix; a woman who is not engaged misses it whether or not she is due.

None of these studies is a trial, and all three rest on self-report in national surveys, which is a real limitation: women may misremember whether a test was done or which test it was. The hysterectomy study in particular relies on participants correctly reporting both their surgical history and their screening history.

What they jointly establish is a targeting failure in both directions, in a programme whose coverage figures look reasonable. Coverage is not the same thing as reaching the right people, and Korea's cervical programme is currently a demonstration of the difference.

Sources

  1. 1

    Shin JY, Choi KS, Suh M, Park B, Jun JK

    Comparison of cervical cancer screening among women with and without hysterectomies: a nationwide population-based study in Korea

    BMC Cancer 2018;18(1):810

    doi:10.1186/s12885-018-4723-9 · PMID:30098592

    https://doi.org/10.1186/s12885-018-4723-9
  2. 2

    Shin HY, Lee YY, Song SY, Park B, Suh M, Choi KS, Jun JK

    Trends in cervical cancer screening rates among Korean women: results of the Korean National Cancer Screening Survey, 2005-2020

    Journal of Gynecologic Oncology 2022;33(4):e39

    doi:10.3802/jgo.2022.33.e39 · PMID:35320888

    https://doi.org/10.3802/jgo.2022.33.e39
  3. 3

    Kim JY, Hong J, Yoon J, Park J, Kim TH

    Regularity of cervical cancer screening in Korea: analysis using national public data for 12 years

    Journal of Gynecologic Oncology 2024;35(2):e18

    doi:10.3802/jgo.2024.35.e18 · PMID:37921602

    https://doi.org/10.3802/jgo.2024.35.e18