Background: Cervical cancer is preventable, and the World Health Organization set the target to eliminate it by 2030. Estonia compared to many other European countries has faced higher cervical cancer incidence and mortality rates. In Estonia, cervical cancer screening was opportunistic, however, since 2006 the population-based screening with Pap smear was implemented. 
Objectives: This study aimed to compare the time-trends of cervical cancer incidence and mortality rates between 1991-2005 and 2006-2020 to assess the 15-year periods before and after the implementation of organized screening.
Methods: Data on cervical cancer (ICD-10, C53) age-specific incidence rates and death numbers were obtained from the Estonian Cancer Registry. Age-standardized incidence rates were calculated using the age-specific incidence rates. Census population data by age group (2000 for 1991-2005 and 2011 for 2006-2020) were used to calculate the age-standardized mortality rates. All age-standardized rates were calculated using the European Standard Population 2013. Trends in incidence and mortality over time were analyzed using the annual percentage change by log-linear regression in R statistics software. 95% confidence intervals were considered.
Results: Trends in cervical cancer age-standardized incidence rates showed a decrease by 0.23% (95% CI: [-1.32%, 0.88%]) annually from 1991 to 2005 and followed by a significant decline of 2.71% (95% CI: [-4.2%, -1.19%]) annually from 2006 to 2020. In this period, in age-groups 30-39, 40-49 and 80+ significant declines were observed by APC = -4.06 (p<0.024), APC = -5.58 (p< 0.001), APC = -4.14 (p = 0.012) respectively. Trends in age-standardized mortality rates showed a significant annual reduction by 3.47% (95% CI: [-4.97%, -1.95%]) from 1991 to 2005, however from 2006-2020, the decline in mortality rates was not statistically significant, APC = -0.38 (95% CI: [-1.6, 0.86]).
Conclusions: Although population-based Pap smear screening with active invitation contributed to a significant decline in incidence rates in Estonia, it might not be sufficient to reduce the mortality rates. New screening and treatment methods, as well as effective strategies to promote participation in screening are needed.