125 Cervical cancer screening among marginalized women Introduction Cervical cancer is the fourth most common cancer in women worldwide.1 The main cause of cervical cancer is a chronic infection with high-risk human papillomavirus (HR-HPV). Although around 80% of the women get infected with this virus, only one percent of the infected women develop cervical cancer.2 Risk factors for a chronic HR-HPV infection are smoking, a history of chlamydia, herpes, (a history of having) multiple sexual partners, an early sexarche and immune system deficiencies.3 Mortality from cervical cancer is preventable when detected and treated in an early or precursor stage. Therefore, many countries organize a national cervical cancer screening program (CSP), for early diagnosis. In the Netherlands, all women between 30-60 years of age are invited to participate in the regionally coordinated national CSP every five years. Invitation is by mail, send to a registered home address. Attendance is voluntary and the primary screening test is free of charge. Women are invited to make an appointment with their general practitioner (GP) for having a cervical smear, or (since 2017) can order a self-sampling HR-HPV-test. Analysis is stepped and starts with a HR-HPV test. In case of a positive test for HRHPV, a subsequent cytological analysis will be performed.4 In 2018 61% of all eligible women participated in the Dutch cervical CSP.5 Despite the availability of a CSP, half of all women that developed cervical cancer were never or insufficiently screened.6 In the Netherlands, characteristics correlating with low screening uptake are: being born outside the Netherlands, living in an urban region, low socio-economic status (SES), and a younger age.3,7 Sex workers living in unstable conditions, homeless women, and undocumented women – from now on referred as: marginalized women – share those characteristics and are often not registered with the municipality, lack a permanent address, or are not registered at all. Therefore, they often fail to receive the invitation letters, or are not invited at all. Moreover, these women face various access barriers to regular healthcare, and they are confronted with other priorities than partaking in preventive services.8-10 Prior studies have showed how hard it can be to engage marginalized women in screening programs. Even after removing healthcare and financial barriers, 38% of the homeless women would still decline a cervical screening smear.11 Marginalized women often face multiple risk factors for a chronic HR-HPV infection and consequently, for cervical cancer. A study in the United States of America (US) showed a 4.4 times higher incidence of cervical cancer in homeless women, compared with the average female population, making cervical cancer the third most common type of cancer in this specific population.12 5
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