title: The Participation of HPV-Vaccinated Women in a National Cervical Screening Program: Population-Based Cohort Study.
abstract: BACKGROUND
  Concerns have been raised that HPV-vaccination might affect women's cervical screening behavior. We therefore investigated the association between opportunistic HPV-vaccination and attendance after invitation to cervical screening.
  
  
  METHODS
  A cohort of all women resident in Sweden, born 1977-1987 (N=629,703), and invited to cervical screening, was followed October 2006 - December 2012. Invitations to screening were identified via the National Quality Register for Cervical Cancer Prevention, as was the primary outcome of a registered smear. Vaccination status was obtained from two nationwide health data registers. Hazard ratios (HR) were estimated using Cox regression adjusted for age, education level and income (HRadj). Women were individually followed for up to 6 years, of which the first and second screening rounds were analyzed separately.
  
  
  RESULTS
  Screening attendance after three years of follow-up was 86% in vaccinated women (N=4,897) and 75% in unvaccinated women (N=625,804). The crude HR of screening attendance in vaccinated vs. unvaccinated women was 1.31 (95% CI 1.27-1.35) in the first screening round. Adjustment for education and income reduced but did not erase this difference (HRadj=1.09, 95% CI 1.05-1.13). In the second screening round, attendance was likewise higher in HPV-vaccinated women (crude HR=1.26, 95% CI 1.21-1.32; HRadj=1.15, 95% CI 1.10-1.20).
  
  
  CONCLUSIONS
  HPV-vaccination is so far associated with equal or higher attendance to cervical screening in Sweden in a cohort of opportunistically vaccinated young women. Most but not all of the difference in attendance was explained by socioeconomic differences between vaccinated and unvaccinated women. HPV vaccine effectiveness studies should consider screening attendance of HPV-vaccinated women when assessing incidence of screen-detected cervical lesions.
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Eva
authors.initials: E
authors.lastname: Herweijer
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom.
authors.forename: Adina L
authors.initials: AL
authors.lastname: Feldman
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Alexander
authors.initials: A
authors.lastname: Ploner
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Lisen
authors.initials: L
authors.lastname: Arnheim-Dahlström
authors.affiliation: Public Health Agency of Sweden, Stockholm, Sweden.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Uhnoo
authors.affiliation: Public Health Agency of Sweden, Stockholm, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden; Department of Occupational and Environmental Dermatology, Skåne University Hospital, Malmö, Sweden.
authors.forename: Eva
authors.initials: E
authors.lastname: Netterlid
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Joakim
authors.initials: J
authors.lastname: Dillner
authors.affiliation: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Pär
authors.initials: P
authors.lastname: Sparén
authors.affiliation: Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Karin
authors.initials: K
authors.lastname: Sundström
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000523:psychology*; D027383:Papillomaviridae / Q000502:physiology; D030361:Papillomavirus Infections / Q000175:diagnosis* / Q000523:psychology* / Q000821:virology; D053918:Papillomavirus Vaccines / Q000627:therapeutic use*; D010358:Patient Participation; D011379:Prognosis; D013548:Sweden / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000453:epidemiology / Q000821:virology*; D014611:Vaccination / Q000523:psychology* / Q000706:statistics & numerical data; D055815:Young Adult
chemical_list: D053918:Papillomavirus Vaccines