title: The end of the decline in cervical cancer mortality in Spain: trends across the period 1981-2012.
abstract: BACKGROUND
  In Spain, cervical cancer prevention is based on opportunistic screening, due to the disease's traditionally low incidence and mortality rates. Changes in sexual behaviour, tourism and migration have, however, modified the probability of exposure to human papilloma virus among Spaniards. This study thus sought to evaluate recent cervical cancer mortality trends in Spain.
  
  
  METHODS
  We used annual female population figures and individual records of deaths certified as cancer of cervix, reclassifying deaths recorded as unspecified uterine cancer to correct coding quality problems. Joinpoint models were fitted to estimate change points in trends, as well as the annual (APC) and average annual percentage change. Log-linear Poisson models were also used to study age-period-cohort effects on mortality trends and their change points.
  
  
  RESULTS
  1981 marked the beginning of a decline in cervical cancer mortality (APC(1981-2003): -3.2; 95% CI:-3.4;-3.0) that ended in 2003, with rates reaching a plateau in the last decade (APC2003-2012: 0.1; 95% CI:-0.9; 1.2). This trend, which was observable among women aged 45-46 years (APC(2003-2012): 1.4; 95% CI:-0.1;2.9) and over 65 years (APC(2003-2012): -0.1; 95% CI:-1.9;1.7), was clearest in Spain's Mediterranean and Southern regions.
  
  
  CONCLUSIONS
  The positive influence of opportunistic screening is not strong enough to further reduce cervical cancer mortality rates in the country. Our results suggest that the Spanish Health Authorities should reform current prevention programmes and surveillance strategies in order to confront the challenges posed by cervical cancer.
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. mcervantes@externos.isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. mcervantes@externos.isciii.es.
authors.forename: Marta
authors.initials: M
authors.lastname: Cervantes-Amat
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. glabente@isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. glabente@isciii.es.|Puerta de Hierro Biomedical Research Institute, C/ Joaquín Rodrigo, 2, 28222, Majadahonda, Spain. glabente@isciii.es.
authors.forename: Gonzalo
authors.initials: G
authors.lastname: López-Abente
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. naragones@isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. naragones@isciii.es.|Puerta de Hierro Biomedical Research Institute, C/ Joaquín Rodrigo, 2, 28222, Majadahonda, Spain. naragones@isciii.es.
authors.forename: Nuria
authors.initials: N
authors.lastname: Aragonés
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. mpollan@isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. mpollan@isciii.es.|Puerta de Hierro Biomedical Research Institute, C/ Joaquín Rodrigo, 2, 28222, Majadahonda, Spain. mpollan@isciii.es.
authors.forename: Marina
authors.initials: M
authors.lastname: Pollán
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. rpastor@isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. rpastor@isciii.es.|Puerta de Hierro Biomedical Research Institute, C/ Joaquín Rodrigo, 2, 28222, Majadahonda, Spain. rpastor@isciii.es.
authors.forename: Roberto
authors.initials: R
authors.lastname: Pastor-Barriuso
authors.affiliation: Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Avda Monforte de Lemos 5, 28029, Madrid, Spain. bperez@isciii.es.|Cancer and Environmental Epidemiology Unit, National Centre for Epidemiology, Carlos III Institute of Health, Avda Monforte de Lemos 5, 28029, Madrid, Spain. bperez@isciii.es.|Puerta de Hierro Biomedical Research Institute, C/ Joaquín Rodrigo, 2, 28222, Majadahonda, Spain. bperez@isciii.es.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Pérez-Gómez
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D027383:Papillomaviridae / Q000472:pathogenicity; D013030:Spain / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000401:mortality* / Q000473:pathology / Q000821:virology; D055815:Young Adult