134 Chapter 5 tailor-made approach for engaging this population in cervical cancer screening is very time-consuming and greatly depends on the availability of a network and the setting, which has proven the major drawback of this approach. The age boundaries of cervical CSPs do differ between countries, and are under constant review.14,20,21 Because of the assumption that marginalized women are being exposed to the risk factors for cervical cancer earlier in life, leading to cervical cell abnormalities at a younger age, the age limits for eligible women in the study were extended to the age of 20, instead of 30. A second PR calculation included these younger women and, before calculation, the screen-positive prevalence rate was equated to the prevalence rate from age cohort 30-35 years of age. This since the Dutch CSP is not screening women between 20-30 years of age and therefore no age specific prevalence rates are known. This is most probably an underestimation. HR-HPV infections will be more prevalent among younger women but will most often be transient, and thus will not progress into cervical lesions. HR-HPV testing for women younger than 25 years has a low specificity and creates a risk of over-referral and overtreatment. When screening for (pre)cancerous cervical abnormalities in women below the age of 25, cytology should be the primary screening method.22 However, including these younger women in the PR calculation, does show an increase of the PR-ratio. This suggests inclusion of women between the age of 25-30 in a high-risk group – such as marginalized women – with an early exposure to HPV, is justifiable and advisable. Clear arrangements were made with the participating women concerning follow-up and how these results would be reported back. In total 12 participants needed referral to a gynaecologist, which eventually were all managed successfully. Nevertheless, it was crucial to have a back-up municipal safety-net team. One of the 12 referred participants missed out on the second appointment with the gynaecologist, due to a transfer to a safe house in another region. She was traced and referred to a gynaecologist in the other region. Another referred participant did not make an appointment with the gynaecologist due to an emergency admission in a detox facility. After being traced, she needed a new referral. Tracing all the participants who needed a repeat cervical smear after six months as part of the follow-up proved the most challenging. All women could be traced through the public health safety-net team. Future implementation studies should further explore these challenges regarding the follow-up, and most ideally tackle these logistical problems beforehand. The study included undocumented and European (non-Dutch) women, who are unable to partake in the Dutch cervical CSP. The reason for including these women, was that they are assigned to the care of streetdoctors, and they also face a high prevalence
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