Social inequalities in timely follow-up of abnormal cervical cancer screening results in Belgium

Background

Cervical cancer screening (CCS) is only effective if abnormal results are followed up promptly. Social inequalities in CCS participation are well documented, but whether they persist in follow-up among screened women remains a critical knowledge gap. Leveraging linked data from three national administrative Belgian sources, this population-based study identifies determinants of untimely follow-up to support the effectiveness and equity of CCS.

Methods

A retrospective population-based cohort study was conducted of 149,198 women aged 25–64 in Flanders with at least one abnormal pap smear (2014–2023), drawing on linked data from the Belgium Cancer Registry (CCS and follow-up data), Intermutualistic Agency (healthcare reimbursement data), and Statbel (socio-economic and -demographic data). Timely follow-up: within 12 months (high-grade) or 24 months (low-grade lesions). Stratified Cox regression (by lesion grade) examined time-to-follow-up, Poisson regression estimated relative risks. Both models adjusted for determinants included: socio-demographic, socio-economic and health-related determinants.

Results

Overall, 21.3% received untimely or no follow-up, with 8.1% among high-grade (HPV+/noHPV) and 27.5% among low-grade (HPV-). Untimely or no follow-up decreased in 2014-2023. Social gradients were small but consistent after full adjustment. Notably, unemployed (RR 0.97, 95% CI 0.96-0.98), non-Belgian (RR 0.96, 95% CI 0.95-0.96), lowest educated (RR 0.93, 95% CI 0.92-0.95), lowest income (RR 0.93, 95% CI 0.92-0.94) and GP-screened women (RR 0.95, 95% CI 0.94-0.95) were less likely to receive timely follow-up.

Conclusions

This study reveals small but consistent social inequalities in timely follow-up, independent of lesion severity, extending the well-known gap into the post-screening phase, albeit smaller than in CCS participation. Improving timely follow-up requires interventions designed with equity in mind, to avoid exacerbating existing social disparities.

Key messages

• Social inequalities in cervical cancer screening participation extend into the post-screening phase: disadvantaged women are less likely to receive timely follow-up after an abnormal result.

• Interventions to improve timely cervical cancer screening follow-up must be equity-conscious: without careful design, they risk widening existing social disparities in cancer prevention.