Nationwide Study on the Cervical Cancer Screening Pathway in Estonia

Effective cervical cancer screening and progress toward WHO elimination targets depend on complete follow-up for women with positive primary screening tests. However, real-world data on this critical step in hrHPV-based screening programs in Eastern Europe are scarce. We conducted a nationwide, population-based retrospective cohort study in Estonia, analyzing records from the Estonian Health Insurance Fund and Population Register. We included 44,282 women aged 30-65 who were invited to hrHPV-based screening between January 1, 2021, and December 31, 2022, with follow-up through March 31, 2024. Screening attendance was 45.7% (n = 20,242; 95% CI: 45.2%-46.2%), with 8.0% (n = 1615; 95% CI: 7.6%-8.4%) testing hrHPV-positive. A substantial loss to follow-up was observed: 57.7% of hrHPV-positive women did not undergo repeat hrHPV testing, colposcopy, or any post-colposcopy care within 12 months. Among those referred for further diagnosis, colposcopy was performed in 77.9% within 6 months. Treatment for High-Grade Squamous Intraepithelial Lesion (HSIL) cases was high (85.5%; n = 124; 95% CI: 78.7%-90.5%), mostly within 3 months. Predictors of lower follow-up adherence included older age and residence in South Estonia. Suboptimal screening uptake and high loss to follow-up among hrHPV-positive women are significant barriers to effective cervical cancer prevention in Estonia. These challenges mirror those seen in many organized screening programs globally. Prioritizing strategies to enhance follow-up adherence is critical for timely diagnosis and treatment, ultimately accelerating global efforts toward cervical cancer elimination.