Background and purpose: Human papillomavirus (HPV) causes multiple cancers. Understanding HPV-related cancer burden may help implement effective strategies for cancer prevention. The aim was to examine incidence and survival trends of eight HPV-related cancer sites in Estonia and estimate the number of cases attributable to HPV. Patient/material and methods: The Estonian Cancer Registry provided data on all cases of eight HPV-related cancer sites diagnosed in Estonia during 1995–2022. Age-standardized incidence trends were analyzed using joinpoint regression, estimating annual percentage change (APC). The number of HPV-attributable cases was estimated using internationally derived site-specific attributable fractions, as tumor HPV status was not available. Five-year relative survival ratios were calculated from national life tables. Results: In all, 11,266 cases of HPV-related cancer sites were diagnosed, of which 6,263 were estimated to be attributable to HPV; over 40% occurred before age 55. In women, estimated average annual number of HPV-attributable cases nearly quadrupled for oropharyngeal cancer (OPC) and tripled for anal cancer. A significant increase in OPC and anal cancer incidence was observed among women (APC 10.0 and 3.8, respectively). Cervical cancer incidence declined after 2012 (APC –5.6). Survival improved for OPC in men (from 13 to 44%) and vaginal cancer in women (from 45 to 73%). Interpretation: HPV-related cancer patterns in Estonia are shifting from cervical to non-cervical cancers. Increasing oropharyngeal and anal cancer incidence highlights the need for prevention strategies beyond cervical screening alone. Strengthening HPV vaccination uptake and sustaining organized cervical screening are critical for reducing future cancer burden.

Human papillomavirus self-sampling may improve cervical cancer screening uptake and equity in cancer prevention. This study aimed to identify sociodemographic factors associated with preference for self-sampling in opt-out (mailed directly) and opt-in (web-order) strategies. The study population included screening participants in the intervention group of a randomized study within the Estonian cervical screening target population in 2021. Preference for self-sampling over clinician sampling was studied among screening participants in opt-out (n = 5335) and opt-in (n = 4362) arms in relation to sociodemographic factors; prevalence ratios with 95% confidence intervals (CI) were calculated using Poisson regression. More women preferred self-sampling in the opt-out than in the opt-in arm (47.6 vs. 23.0%; P < 0.001). In the opt-out arm, self-sampling preference was higher among women aged 60/65 years (multivariable prevalence ratios: 1.36, 95% CI = 1.25-1.48, P < 0.001) compared with age group 30/35 years. In the opt-in arm, self-sampling preference was lower among women aged 50/55 years (prevalence ratios: 0.68, 95% CI = 0.57-0.81, P < 0.001) and 60/65 (prevalence ratios: 0.83, 95% CI = 0.70-0.99, P = 0.036) compared with age group 30/35 years, and other native language speakers were 46% (P < 0.001) less likely to choose self-sampling compared with native Estonian speakers. Uninsured women were more likely to prefer self-sampling, regardless of strategy. The study findings support the implementation of different targeted opt-out or opt-in approaches in various sociodemographic groups in Estonia. Each country should evaluate appropriate context-specific strategies for its population subgroups.

Introduction Prevalence of high risk human papillomavirus (hrHPV) and its subtypes by sociodemographic factors and the related cytological findings in the Estonian cancer screening population were examined, with the aim to improve cancer prevention. Methods This cross-sectional study included all women who participated in the Estonian cervical cancer screening programme from January 1, 2021 to January 31, 2022 and had a valid HPV test result reported to the Estonian Cancer Screening Registry (n = 37 537, aged 30, 35, 40, 45, 50, 55, 60, and 65). Limited sample (N = 18 784) within the total sample consisted of women who used self-sampling (N = 3535) or whose clinician collected sample was analysed using lab methodology that differentiates HPV16, 18, and 45. Data on HPV and cytology results were obtained from the Estonian Cancer Screening Registry, whereas data on education, nationality, and marital status were obtained from the Estonian Population Registry. Results hrHPV was detected in the samples of 3307 (8.8%) women, and the prevalence was significantly higher in age groups under 40, in women with lower education, of Estonian nationality, and with no partner. The overall prevalence of HPV16 was 1.8%, ranging from 4.4% in 30-year-old women to 0.9% in 55-year-old women. The proportion of normal cytology was 50% among all hrHPV positive women and 35% in all HPV16 positive women, while it was 47% for HPV16 alone and 24% for HPV16 plus other hrHPV subtypes. The probability of normal cytology was significantly higher in women aged 50 and older compared to women aged 30 and 35 for total hrHPV and HPV16. Conclusion All countries should monitor HPV prevalence across different age groups. As different HPV genotypes have a different oncogenic risk profile, extended or complete genotyping would help personalised risk-based screening approaches, with less health care costs, less harms, and a bigger net benefit. In addition, lab methodology should be harmonised.

BACKGROUND:Cervical and corpus uteri cancer mortality may be underestimated due to a proportion of deaths attributed to unspecified uterine cancer. The aim was to estimate corrected mortality rates and trends for cervical and corpus uteri cancer in Estonia after reallocation of underlying cause of death using individual linkage of death records and cancer registry records. METHODS:Deaths in Estonian female population in 2000-2021 with the underlying cause of cervical cancer (ICD-10 code C53), corpus uteri cancer (C54) or cancer of uterus not otherwise specified (C55) were individually linked to Estonian Cancer Registry to identify any cancers diagnosed in these persons. Underlying cause of death was reallocated if applicable. Original and corrected age-standardized (world) mortality trends were modelled using joinpoint regression. RESULTS:During 2000-2021, the corrected number of deaths was 1409 cervical cancer deaths (originally 1388, 1.5 % increase), 1146 corpus uteri cancer deaths (902, 27 % increase), and 50 unspecified uterine cancer deaths (368, 86 % decrease). Proportion of unspecified deaths decreased from 26 % (2000-2004) to 4 % (2016-2021) (p < 0.001). After correction, cervical cancer mortality trend steepened slightly from 0.8 % decrease per year to 1.1 % decrease (both significant). Corpus uteri cancer mortality trend changed direction from significant increase of 1.9 % per year to significant decrease of 1.4 % per year. CONCLUSIONS:Routine linkage of causes of death records with cancer registry is warranted for validating underlying cause of death. The results emphasize the importance of the availability of medical documentation for physicians assigning cause of death as well as relevant training.

INTRODUCTION:The proportion of cesarean section (CS) deliveries has increased worldwide. This study aimed to analyze CS trends in Estonia from 1992 to 2023 in total and according to Robson 1+2 (nulliparous, single cephalic, ≥37 weeks, spontaneous labor, induced or CS before labor) and 5 (previous CS, single, cephalic, ≥37 weeks) criteria. METHODS:Data of all deliveries (n=446536) in Estonia from 1992 to 2023 were obtained from the Estonian Medical Birth Registry. During the study period, 73960 births ended in CS. Descriptive characteristics of the study population were divided into two periods (1992-2007 increasing trend; 2008-2023 stable trend). Robson 1+2 and 5 sub-groups were analyzed. Joinpoint regression was used to estimate the change in CS trends in Robson groups over time. RESULTS:The total proportion of CS increased from 6.5% in 1992 to 20.9% in 2007 and remained stable after that. Robson 1+2 proportion increased from 5% to 21% in 2023, and Robson 5 decreased from 73% to 56%. In 2023, R1+R2 combined with R5 accounted for more than half (63%) of all CSs. CONCLUSIONS:The increase in CS occurred primarily due to the increase in CS rates among nulliparous women with a singleton pregnancy at term. More attention must be given to nulliparous women to prevent CS and maintain vaginal births after CS. To improve the quality of maternity care, it is essential to monitor the indicators of CS based on Robson's criteria.

Aim: Our study aimed to analyse trends in peripartum care and outcomes in Estonia over the period from 1992 to 2021.

Background Despite the relatively low breast cancer incidence in Estonia, mortality remains high, and participation in mammography screening is below the recommended 70%. The objective of this register-based study was to evaluate incidence-based (IB) breast cancer mortality before and after the introduction of organized mammography screening in 2004. Methods Breast cancer deaths individually linked to breast cancer diagnosis were obtained from the Estonian Cancer Registry and used for calculating IB mortality. We compared age-specific IB mortality rates across 5-year birth cohorts and 5-year periods. Poisson regression was used to compare IB mortality for one age group invited to screening (50-63) and three age groups not invited to screening (30-49, 65-69, and 70+) during two periods before and after screening initiation (1993-2003 and 2004-2014). Joinpoint regression was used for age-standardized incidence and IB mortality trends. Results Age-standardized IB mortality has been decreasing since 1997. Age-specific IB mortality for birth cohorts never exposed to screening showed a continuous increase with age, while in cohorts exposed to organized screening the mortality curve flattened or declined after the age of first invitation. Significant decreases in mortality from 1993-2003 to 2004-2014 were seen in the 30-49 (age-adjusted rate ratio 0.51, 95% CI 90.42-0.63) and 50-63 (0.65, 95% CI 0.56-0.74) age groups, while no decline was seen in the 65-69 and 70+ age groups. Conclusions The age specific IB mortality curves in birth cohorts exposed to screening and the significant mortality decline in the target age group after the initiation of the organized program suggest a beneficial effect of screening. Improved treatment without screening has not reduced mortality in older age groups. Our results support raising the upper screening age limit to 74 years.

Proportion of normal deliveries is decreasing worldwide. This study analysed operative vaginal deliveries (OVD) and Caesarean sections (CS) with some background factors in Estonia and Finland from 1992 to 2016. Data on all deliveries from 1992 to 2016 were obtained from the Finnish Medical Birth Registry (1 481 160 births) and the Estonian Medical Birth Registry (356 063 births). Time trends were analysed by joinpoint regression, and factors associated with OVD and CS by logistic regression. Odds ratios with 95% CIs were calculated, adjusted for year, maternal age, foetal birthweight, and use of epidural/spinal anaesthesia. One out of four deliveries were operative in Estonia and in Finland by 2016. By 2016, the Estonian CS rate had tripled to 20.9% and the OVD rate had increased by nine times to 5.6%. In Finland, the CS rate increased slightly to 16.4% while the OVD rate nearly doubled to 9.4%. In Estonia, the incidence of OVD was 24% lower (aOR 0.76, 95% Cl 0.74-0.78) and the incidence of CS 9% higher (aOR 1.09, 95% Cl 1.07-1.10) than in Finland. Use of epidural/spinal anaesthesia and foetal birthweight increased the risk of OVD in both countries, maternal age increased the risk of CS in both countries. Even if the CS and OVD rates are different, operative delivery rates may be similar in different countries. Combined analysis of operative deliveries together with background factors gives a better understanding of the trends in birthcare than monitoring CS rates alone.

Introduction and aims: European labour induction standards are poorly understood. We therefore reviewed the most recent induction of labour (IOL) guidelines in several European countries to assess their recommendations on pharmacological first-line interventions.

Background Cervical cancer incidence in Estonia ranks among the highest in Europe, but screening attendance has remained low. This randomized study aimed to evaluate the impact of opt-in and opt-out human papillomavirus (HPV) self-sampling options on participation in organized screening. Methods A random sample of 25,591 women were drawn from the cervical cancer screening target population who were due to receive a reminder in autumn 2021 and thereafter randomly allocated to two equally sized intervention arms (opt-out and opt-in) receiving a choice between HPV self-sampling or clinician sampling. In the opt-out arm, a self-sampler was sent to home address by regular mail; the opt-in arm received an e-mail containing a link to order a self-sampler online. The remaining 30,102 women in the control group received a standard reminder for conventional screening. Participation by intervention arm, age and region of residence was calculated; a questionnaire was used to assess self-sampling user experience. Results A significant difference in participation was seen between opt-out (41.7%) (19.8% chose self-sampling and 21.9% clinician sampling), opt-in (34.1%) (7.9% self-sampling, 26.2% clinician sampling) and control group (29.0%, clinician sampling only). All age groups and regions in the intervention arms showed higher participation compared to the control group, but the size of the effect varied. Among self-sampling users, 99% agreed that the device was easy to use and only 3.5% preferred future testing at the clinic. Conclusion Providing women with a choice between self-sampling and clinician sampling significantly increased participation in cervical cancer screening. Opt-in and opt-out options had a different effect across age groups, suggesting the need to adapt strategies.

IntroductionThe number of cesarean sections (CSs) has grown steadily, but the underlying factors driving this increase remain unknown. Data from Medical Birth Registries were retrieved to analyze CS trends in Estonia and Finland during the period 1992-2016. Material and methodsAll births in Estonia (n = 356 063) and Finland (n = 1 437 234) were included. The differences between Estonia and Finland in five-year time periods for the total CS rate, and rates in Robson 1, 2, and 5 groups (R1, R2, R5) were analyzed by logistic regression. Total CS rates were adjusted for birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother's age. R1; R2; R5 rates were adjusted for birthweight and mother's age. ResultsIn Estonia, the proportion of CSs increased from 6.5% to 21.0% and in Finland from 15.1% to 16.8% between 1992 and 2016. In 2016, Estonia and Finland remained within the target value with their R1 + 2 (Estonia 18%; Finland 16%) and R5 (Estonia 59%; Finland 42%) values. ConclusionsComparing Robson groups in different countries can shed light on divergent CS rates and to improve the quality of perinatal and obstetric care.

INTRODUCTION:Data from different countries show partly controversial impact of SARS-CoV-2 infection on pregnancy outcomes. A nationwide register-based study was conducted in Estonia to assess the impact of SARS-CoV-2 infection at any time during pregnancy on stillbirth, perinatal mortality, Apgar score at 5 minutes, cesarean section rates, rates of preterm birth and preeclampsia. MATERIAL AND METHODS:Data on all newborns and their mothers were obtained from the Estonian Medical Birth Registry, and data on SARS-CoV-2 testing dates, test results and vaccination dates against SARS-CoV-2 from the Estonian Health Information System. Altogether, 26 211 births in 2020 and 2021 in Estonia were included. All analyses were performed per newborn. Odds ratios with 95% confidence intervals (CI) were analyzed for all outcomes, adjusted for mother's place of residence, body mass index, age of mother at delivery and hypertension and for all the aforementioned variables together with mother's vaccination status using data from 2021 when vaccinations against SARS-CoV-2 became available. For studying the effect of a positive SARS-CoV-2 test during pregnancy on preeclampsia, hypertension was omitted from the models to avoid overadjustment. RESULTS:SARS-CoV-2 infection during pregnancy was associated with an increased risk of stillbirth (adjusted odds ratio [aOR] 2.81; 95% CI 1.37-5.74) and perinatal mortality (aOR 2.34; 95% CI 1.20-4.56) but not with a lower Apgar score at 5 minutes, higher risk of cesarean section, preeclampsia or preterm birth. Vaccination slightly decreased the impact of SARS-CoV-2 infection during pregnancy on perinatal mortality. CONCLUSIONS:A positive SARS-CoV-2 test during pregnancy was associated with higher rates of stillbirth and perinatal mortality in Estonia but was not associated with change in preeclampsia, cesarean section or preterm birth rates.

1. Low JA. Operative delivery: yesterday and today. J Obstet Gynaecol Can. 2009;31(2):132-141. doi:10.1016/s1701-2163(16)34097-x CrossRef Google Scholar

Abstract Background Cervical cancer incidence and mortality rates remain high in Estonia and participation in organized cervical cancer screening program is low. The aim of this pilot study was to estimate the impact of offering an HPV self-sampling option on screening uptake. Methods A randomized intervention study was conducted within Estonian organized cervical cancer screening program in 2021. Among target group women who had not participated in screening by August 2021, 26,000 women were randomly selected and allocated to two equally sized intervention arms offering a choice between attending a clinic or taking a self-sample. The opt-out group received a Qvintip sampler by regular mail to home address, the opt-in group received by e-mail a link to order the sampler from a web-site. A control group of 32,000 women received the usual reminder to attend screening at a clinic. Participation rates were calculated and data on user experience were collected with a questionnaire. Results Significant difference in participation rates was observed between opt-out (41%) (among them 20% chose self-sampling, 21% chose clinic attendance), opt-in (34%) (8% self-sampling, 26% clinic) and control group (28%). Intervention arms showed higher screening uptake in all age-groups and regions, but the largest effect was seen at ages 60 and 65 years and in regions showing the lowest screening participation rates. Among self-sampling users, 99% agreed that self-sampling was easy and only 3% prefer testing at a clinic. Conclusions Offering women a choice between HPV self-sampling or attending a clinic significantly increased cervical cancer screening uptake. Sending an HPV self-sampling kit to home address was the most effective approach. Majority of women who chose HPV self-sampling want to use this option in the future. HPV self-sampling should be integrated in the cervical cancer screening program in Estonia. Key messages

Background Cervical cancer incidence and mortality in Estonia are among the highest in Europe, although the overall coverage with cervical cytology is high. This indicates potential issues with the quality of collection and/or laboratory evaluation of cervical cytology. Objectives The aim of the retrospective observational study was to assess the quality of cervical cytology specimen collection, evaluation, and reporting using laboratory reports in Estonia. Methods The study included women with a cervical cancer diagnosis in 2017−2018. Cervical cytology and histology reports for these women in 2007−2018 were obtained from ten laboratories. We described the quality of cytology specimen collection and reporting of cytology results. Multivariate logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI) to identify factors associated with NILM as the last cervical cytology result within 5 or 2 years before the cervical cancer diagnosis. Also, we calculated cytology-histology correlation (CHC). Results We identified 503 cytology and 100 histology reports from 138 women. The laboratories differed greatly regarding human resources, work capacity and volume. Differences between local and regional laboratories were observed in reporting specimen adequacy (P < .001). We found that local laboratories had 3 times higher odds (OR = 2.95, 95% CI: 1.05−8.33) of reporting normal results 2 years before cancer diagnosis than regional laboratories. According to the CHC, 58.9% of pairs were in agreement. Conclusions The study showed considerable heterogeneity and suboptimal performance of cervical cytology practices in Estonia, particularly at local laboratories. Efforts to improve laboratory quality assurance are crucial.

There are currently screening programmes for breast, cervical and colorectal cancer in many European countries. However, the uptake of cancer screening in general may vary within and between countries. The aim of this study is to assess the inequalities in testing utilization by socio-economic status and whether the amount of inequality varies across European regions. We conducted an analysis based on cross-sectional data from the second wave of the European Health Interview Survey from 2013 to 2015. We analysed the use of breast, cervical, and colorectal cancer testing by socio-economic position (household income, educational level and employment status), socio-demographic factors, self-perceived health and smoking behaviour, by using multinomial logistic models, and inequality measurement based on the Slope index of inequality (SII) and Relative index of inequality (RII). The results show that the utilization of mammography (Odds Ratio (OR) = 0.55, 95% confidence interval (95%CI):0.50-0.61), cervical smear tests (OR = 0.60, 95%CI:0.56-0.65) and colorectal testing (OR = 0.82, 95%CI:0.78-0.86) was overall less likely among individuals within a low household income compared to a high household income. Also, individuals with a non-EU country of birth, low educational level and being unemployed (or retired) were overall less likely to be tested. The income-based inequality in breast (SII = 0.191;RII = 1.260) and colorectal testing utilization (SII = 0.161;RII = 1.487) was the greatest in Southern Europe. For cervical smears, this inequality was greatest in Eastern Europe (SII = 0.122;RII = 1.195). We concluded that there is considerable inequality in the use of cancer tests in Europe, with inequalities associated with household income, educational level, employment status, and country of birth.

Background: Like many Eastern-European countries, Estonia struggles with ineffective cervical cancer (CC) screening. Despite a long-term organised screening programme and high overall Pap-smear coverage, CC incidence and mortality remain very high. The aim of the study was to examine the reasons for high CC incidence in Estonia by analysing the effect of Pap-smears and sociodemographic factors on CC risk. Methods: In this population-based case-control study, women aged >= 25 years with an in situ/invasive CC diagnosed in Estonia in 2011-2017 were defined as cases. Using a density sampling scheme, controls were randomly selected from general population. To estimate CC risk associated with having no Pap-smears during seven years before diagnosis (cases) or index date (controls), place of residence, interruption in health insurance, and several sociodemographic factors, multivariate logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Individual-level data from three population-based registries were used. Results: Among 1439 cases and 4317 controls, proportion of women with no Pap-smears was 53% and 35%, respectively. Women with no Pap-smears were at higher risk for CC (OR=2.35; 95% CI: 1.85-2.98). CC risk was increased among women who were younger, living in more remote regions, lower-educated, or divorced/widowed. Interruption in health insurance was associated with a 23% risk increase. Regional differences in CC risk were observed among screened women. Conclusion: To reduce the risk of CC in Estonia, efforts are necessary to increase screening coverage among high-risk women and ensure the quality of CC screening programme. Screening approaches and communication should be tailored to the needs of different population groups. Further studies are warranted to identify the reasons for regional differences in CC risk.

Introduction and aims of the study: In 2015–2016, the proportion of extremely and very preterm deliveries (22 + 0 to 31 + 6 GW) in Estonia was 1.2%. The Estonian Health Insurance Fund performed an audit to analyse the management and outcome of these deliveries before the national guidelines were implemented. Antenatal, intranatal and postnatal care indicators were analysed. The latter will not be described in the current paper. Methods: Data about deliveries in 22 + 0 to 31 + 6 GW were obtained from the Estonian Medical Birth Registry. Detailed information about these deliveries was collected from the hospitals where they occurred. The proportion of deliveries in 22 + 0 to 31 + 6 GW in different hospitals, the use of maternal corticosteroids, the use of magnesium sulfate for neuroprotection, perinatal mortality rate and the proportion of cesarean sections (CS) was analysed. Results: Altogether 316 children were born from 265 extremely and very preterm deliveries. The proportion of such deliveries in tertiary care hospitals was 1.46% and in other hospitals 0.33%. Maternal corticosteroids were used in 96% of cases, in 38% the timing and dosage was precisely according to international recommendations. Magnesium sulfate for neuroprotection was used for 65% of deliveries occurring from 24 + 0 to 31 + 6 GW, in 72% precisely according to recommendations. Perinatal mortality in 22 + 0 to 32 + 6 GW was 12‰, in 28 + 0 to 31 + 6 GW 9‰. Among deliveries from 24 + 0 to 31 + 6 GW, the proportion of CS among deliveries in cephalic presentation was 48%, for breech presentation 61% and for twins 57%. Conclusions: The centralisation of very preterm deliveries to higher level hospitals works well in Estonia. The use of maternal corticosteroids and magnesium sulfate needs to be assessed again after the implementation of national guidelines for preterm deliveries. The proportion of CS in different groups needs regular evaluation. The reasons of perinatal mortality among very preterm deliveries should be further studied.