Background: Cervical cancer incidence in Brazil remains high, with marked regional inequalities. In Pernambuco, a northeastern state, a Technical Cooperation Agreement was established in 2019 to strengthen cervical cancer control through care pathway reorganisation, development and incorporation of an open-platform HPV DNA test, and implementation of an electronic monitoring system. Persistently high incidence and mortality in the state have been linked to low coverage and limited effectiveness of opportunistic cytology-based screening. In September 2023, the III Health Region initiated organised screening with high-risk HPV testing and timely diagnosis and treatment.
Objectives: To compare downstream cervical cancer care procedures following a positive screening result in the III Health Region, which adopted HPV-based screening, with those in the remaining health regions of Pernambuco that continued cytology-based screening.
Methods: A retrospective time-series analysis was conducted using secondary data from the Brazilian Unified Health System (SUS) information systems. The procedures analysed included colposcopy, biopsy, and excision of the transformation zone (ETZ) and the biopsy to colposcopy ratio among women aged 25–64 years, from 2015 to 2024. APC (annual percentage change) and changes in trend were estimated using joinpoint regression. Differences between the III Health Region and the remaining regions were assessed using joinpoint pairwise comparison tests.
Results: Across the 12 Health Regions of Pernambuco, colposcopy volumes declined from 28,299 to 22,556 colposcopies corresponding to an overall APC of -5.7% (p < 0.001) with the lowest volume in 2020 (12,797) during the COVID-19 pandemic. In the 11 regions that continued cytology-based screening, colposcopy volumes declined significantly over time (APC -5.6%). By contrast, in the III Health Region, procedure volumes remained stable and increased after 2023. Following HPV test implementation, the III Health Region showed a marked increase in biopsies, rising from 96–200 procedures annually in the pre-intervention period to 539 in 2024 with an estimated APC of 134.9% (p = 0.004) for 2022-2024. Similarly, ETZ procedures increased substantially, with an steeper post 2020 increase in the III Health Region (APC 34.4%, p = 0.009). In contrast, regions maintaining cytology-based screening exhibited temporal fluctuations, with sharp reductions in 2020 followed by a slight, non-significant increase thereafter (APC 1.1; p = 0.559). The biopsy to colposcopy ratio showed non coincident trends comparing the III Health Region and the remaining regions (p = 0.02), indicating different patterns of referral and follow-up to and after colposcopy. Overall, these findings indicate a temporal association between organised HPV-based screening and increased diagnostic and therapeutic procedures within the cervical cancer care pathway.
Conclusions: The transition to organised HPV based screening in the III Health Region of Pernambuco was associated with increased downstream diagnostic and therapeutic activity, including marked increases in biopsies and ETZ procedures and a higher biopsy to colposcopy ratio compared with regions maintaining cytology based screening. These findings highlight system level changes in care delivery following programme reorganisation and support continued evaluation of sustainability and downstream effects on detection and outcomes. Further studies are warranted to assess sustainability and potential effects on cervical cancer incidence and mortality.