Strengthening the knowledge base Regional and socio-economic disparities. In 2022, the Cancer Registry produced new cancer statistics and data by among population groups according to educational level. Differences in cancer incidence by educational level were relatively highest for both men and women for lung and tracheal cancer. Incidence among people with primary level education was more than double that at among those with tertiary level education. Regional differences in cancer burden for the most common cancers were largest for lung cancer in women. Differences according to education group and region were reported in the Cancer 2020 statistical publication. In a separate study, changes in regional variation in prostate cancer were investigated using county-level cancer data. Regional variation in incidence has been substantial for decades, but regional differences in prostate cancer mortality have narrowed and no statistically significant differences were found in the most recent annual period. However, prostate cancer mortality was lower on average in municipalities with a high proportion of highly educated people. Delay before diagnosis. The From Symptoms to Patients research project looked at the use of healthcare services by colorectal cancer patients one year before diagnosis. It provides information on service use, patterns of use, and delays in diagnosis and access to cancer treatment. Expanding the knowledge base. The Cancer Registry has launched activities to compile and identify structural variables from existing data that are more useful to users. For example, data mining has been initiated to extract TNM classification of prevalence data from pathology text reports. International research cooperation of the Cancer Registry A joint Nordic study on cancer incidence, mortality and screening participation among migrant women, funded by the Nordic Cancer Union (NCU) and launched in 2021, went ahead as planned. The study has focused on women who have migrated to the Nordic countries from non-Western countries and compared them with the female population of those countries. The results of the study are to be reported in four different publications, of which the manuscripts on cancer incidence and mortality have been sent to the journal for review (main responsibility with the registry) and the other two are in preparation. In 2022, the last research articles of the EU-TOPIA research project (Towards Improved Screening for Breast, Cervical and Colorectal Cancer in All of Europe http://eu-topia.org/), funded by the EU Horizon 2020 programme, in which the Cancer Registry participated, were completed. A simulation modelling study on the cost-effectiveness of colorectal cancer screening in Finland was published (Heinävaara et al. 2022). The study is based on data from the first year of the FIT screening pilot launched in 2019 and on the combination of modelling data for men and women separately. The results of the study were used to select the target population for the colorectal cancer screening programme and the thresholds for the FIT screening test for 2022. The project also explored inequalities in screening-type testing by examining two large anonymous European questionnaires (Bozher et al. 2022). The study found significant inequalities in cervical, breast and colorectal cancer screening by household income, education level, employment status and country of birth. Finland is participating together with Denmark and Sweden in the SALiCC (Socioeconomic Consequences in Adult Life after Childhood Cancer) cohort, which follows the later stages of childhood cancer from a socioeconomic perspective (https://www.cancer.dk/saliccs/). In 2022, the project published an article on occupational status and education, among other topics. In the autumn, the CanScreen-ECIS project, which is preparing the third European Cancer Screening Report, was launched. Its aim is to develop and pilot a new screening data processing environment that can be integrated into the wider European Cancer Information System (ECIS). The project is led by IARC and the Cancer Registry is participating in several work packages. Finland is responsible for the capacity building work package. The Nordic Occupational Cancer Study (NOCCA), a joint Nordic project on cancer risks from occupational exposures coordinated by the Cancer Registry, published a study on the association of socio-economic status with lung cancer risk in the Nordic countries in collaboration with the IARC. Peer-reviewed studies on the cancer risks of occupationally exposed to electromagnetic radiation and on the occupational cancer risks of nasopharyngeal cancer were also published. The international CONCORD-3 study compared the five-year relative survival rates of leukaemia patients under the age of 25 in different countries. The combined survival rate for all types of leukaemia in Finland was 87%. Finland was among the top eight countries, with only Denmark and Iceland having higher survival rates in Europe. In Finland, survival rates for children and young people with leukaemia increased significantly in the 2000s. The cost of cancer treatment. Since 2018, the Cancer Foundation has had an online service open to all, which provides information on the annual costs of cancer treatment by cancer type, region and cost category since 2014. In 2021, a project was implemented to separate the cost of drugs from the cost of hospital care. The online tool, updated with drug data and cost data for 2020, was launched in early 2022. Screening services and implementation An amendment to the government’s screening regulation in August 2021 launched national screening for colorectal cancer in January 2022, based on an immunochemical faecal occult blood test, and extended cervical cancer screening to women aged 65 and over. Thus, in 2022 Finland had three national screening programmes: cervical cancer screening for women aged 30-65, breast cancer screening for women aged between 50 and 69 and the newly launched colorectal cancer screening for everyone aged between 60 and 68. The colorectal cancer screening programme will be progressively extended to women aged between 56 and 74. The introduction of national screening for colorectal cancer increased the number of screening laboratories. Fimlab Oy, which was involved in the pilot phase of the screening, expanded its operations with partner Nordlab Oy from 12 municipalities to 210 municipalities (55% of the target population). The new screening laboratories were Huslab Oy in the Helsinki metropolitan area, North Karelia and Kymenlaakso (33% of the target population), Islab Oy in South and North Savo (8% of the target population) and Synlab Oy in the Joensuu region (4% of the target population). In the Fimlab and Synlab municipalities, the faecal blood test used was the FOB Gold test used in the pilot, and in the municipalities of Huslab and Islab, the new OC Sensor Pledia. The screening programme was launched according to a protocol and test list developed by a group of experts appointed by the National Steering Group for Cancer Screenings. The launch of the new national cancer screening programme was a major workload for the Mass Screening Registry. IT systems were built and screening processes were refined in weekly laboratory meetings. Advice and guidance to municipalities was intensified, with dozens of contacts each week. Online training packages for screening nurses and endoscopists were completed. At the end of 2022, 147 nurses and 122 specialists had completed the online training. Monthly live training sessions were also organised for screening nurses, with 40-60 participants attending regularly. The content of a training package for screening pathologists was being prepared. The screening protocol was refined, including the abolition of the second reminder from 1 January 2023. The revised protocol (Figure 5) was sent to all laboratories. Information on the target schedule for screening colonoscopies was also sent to municipalities. In preparation for the 2023 reform of the social welfare and healthcare system, a letter was sent to the wellbeing services counties, stressing that they will be responsible for organising cancer screening and for contracts with laboratories and screening units. In December 2022, the European Union published updated cancer screening recommendations. They call for a shift in cervical cancer screening to HPV testing and preparation for the screening of vaccinated cohorts. The target population for breast cancer screening should be expanded and the screening protocol for colorectal cancer screening should integrate screening history. It was also recommended that prostate cancer and lung cancer screening should be piloted and introduced through research. The National Steering Group for Cancer Screenings published a position paper on the integration of EU recommendations into the Finnish screening environment. The steering group also established expert groups for prostate and lung cancer screening. The expert groups for cervical, breast and colorectal cancer screening initiated the preparation of quality manuals. The Expert Group on Cervical Cancer Screening published an updated screening protocol, https://syoparekisteri.fi/seulonta/syopaseulontojen-jarjestaminen/, which was distributed to municipalities and wellbeing services counties. The experts (1+7) of the Mass Screening Registry worked in the steering group as well as in all expert groups. The registry also participated in the development of screening pathology for colorectal cancer in a separate pathology group. Expert work. The Director of Screening participated in the National Steering Group for Cancer Screenings as a member and chaired the expert group on colorectal cancer Screening. The Screening Development managers participated in the work of the Cervical and Bowel Cancer Screening Expert Groups as secretaries. The Director of Research was a member of the expert group on breast and colorectal cancer screening. Research related to screening. A study based on test data from cervical cancer screening and non-screening found that pap smear testing at both screening and non-screening intervals was effective at three and five-year intervals (Pankakoski et al. 2022). The most effective testing was from the age of 35 upwards. Out-of-screen testing is concentrated in those under 30 years of age, where the effectiveness of screening is questionable. The increased prevalence of HPV testing in screening programmes has increased referral and detection rates for screening compared to pap tests (Hakkila et al. 2022). However, further screening based on the persistence of HPV infection alone leads to overdiagnosis. The effect of alternative, post-generated HPV screening algorithms on colposcopy burden was studied in relation to pap smear screening (Vahteristo et al. 2022). HPV screening was better at detecting mild to moderate precancerous lesions, a large proportion of which self-heal. The sensitivity and accuracy of HPV screening were best balanced when HPV-positive individuals without cellular changes were followed up for a long time. Further development of the HPV screening algorithm is being investigated in a biological material study to analyse archived samples for more accurate HPV genotypes. In 2022, the study will be licensed and a collaboration agreement has been signed between the Karolinska Institute, HUS, THL and the Cancer Society. The first samples will be sent for genotyping to the Karolinska Institute in spring 2023. These results are reported in more detail in the Cervical Cancer Annual Report A collaborative study on breast cancer screening is underway with Aalto University. The study assesses the cost-effectiveness of extending the screening coverage compared to current screening. The study uses registry data on the impact of screening on cancer prevalence, breast cancer incidence, cancer survival and the costs of screening and treatment. In 2019, a colorectal cancer screening pilot was launched with a separate threshold for the FIT screening test for men and women. In 2020, screening test thresholds were calculated for both genders. The effectiveness of screening and the impact of lowering the threshold were examined using data from the first two years (Kuoppa et al. 2022). Participation in colorectal cancer screening was excellent in both years, higher in women than in men. Lowering the threshold increased the proportion of positive test results for both sexes, but the positive predictive values of detection rates remained unchanged. The first year results have also been used in a cost-effectiveness modelling study (see 6k EU-TOPIA). The Cancer Registry is also conducting a study to further develop screening, including on the basis of risk. Randomised population-based prostate cancer screening trial with PSA. FinRSPC (Finnish Randomized Study of Screening for Prostate Cancer) covers the follow-up of about 80 000 men over 25 years. The main goal of the study has been to investigate the impact of prostate cancer screening on prostate cancer mortality, as well as the cost-effectiveness and quality of life effects of screening. After the intervention phase, the study population is now being followed up by collecting data from different registries. In 2022, the study assessed the risk of prostate cancer in men with a PSA <3 ng/ml: PSA levels <1 had a very low 20-year prostate cancer incidence, while PSA levels of 2-2.99 had a 4-5-fold increase in the incidence of aggressive disease. In addition, the association of other drugs used in the treatment of other diseases (antiepileptic drugs and Allopurinol) with prostate cancer mortality has been investigated. This project, led by the University of Tampere, involves seven ongoing doctoral theses and five dissertations. In total, more than 20 manuscripts were in preparation in 2022. In 2022, Sanni Helandar completed her doctoral thesis entitled Aspects of Lifestyle and Symptoms in Colorectal Cancer Screening: a Population-Based Survey Study in Finland. It found that colorectal cancer screening did not cause adverse changes in lifestyle. Three PhD theses will be completed during the summer or early autumn of 2023. The subjects of the theses are: cervical cancer screening in the Nordic countries in the context of changing primary tests (pap smear, HPV), factors influencing screening activity, and the effectiveness and efficiency of screening and non-screening cervical cancer testing in different age groups.
