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. 2025 Sep 8;158(1):39–44. doi: 10.1002/ijc.70134

Trends in cervical cancer incidence in the Netherlands: A join‐point and age–period–cohort analysis (1989–2023)

Kelly Melisa Castañeda 1, Karin Marianne Vermeulen 1, Maaike van der Aa 2, Ed Schuuring 3, G Bea A Wisman 4, Geertruida Hendrika de Bock 1,✉
PMCID: PMC12588549  PMID: 40920063

Abstract

Cervical cancer remains a significant public health issue, ranking as the fourth most common cancer in women globally. In the Netherlands, cervical cancer incidence declined steadily from 1989 to 2001 but increased between 2001 and 2007. This study updates trends in cervical cancer incidence from 1989 to 2023 in the Netherlands and evaluates the impact of screening practices and participation rates in the national population‐based screening program. This ecological study uses group‐level data from the Netherlands Cancer Registry (1989–2023) to analyze trends across three temporal dimensions—age, period, and cohort—using age–period–cohort analysis and join‐point regression to identify significant changes in trends over time. Cervical cancer incidence declined steadily from 1989 to 2003 but increased from 2003 to 2023, particularly among younger birth cohorts (1976–1995). This increase aligns with the decline in screening participation, which dropped from over 77% before 2003 to below 60% in subsequent years, as well as the introduction of primary high‐risk human papillomavirus testing in 2017, which has higher sensitivity than cytology, leading to more cases being detected and, consequently, an increase in incidence. Trends in cervical cancer incidence in the Netherlands indicate a positive impact of the screening program, with a steady decline over the years. However, efforts should focus on increasing participation in both screening and vaccination, as this is crucial for achieving the goal of reducing incidence to below 4 per 100,000 women, in line with the global strategy to eliminate cervical cancer.

Keywords: early detection of cancer, group‐level data, human papillomavirus viruses, incidence, trends, uterine cervical neoplasms

What's new?

This ecological study of trends in cervical cancer incidence from 1989 to 2023 in the Netherlands indicates a positive impact of screening, with a steady decline over the years. However, incidence increased from 2003 to 2023, particularly among younger cohorts, aligning with reduced participation and the introduction of more sensitive, high‐risk human papillomavirus testing in 2017. With European Standardized Rates ranging from 9.4 to 13.8 per 100,000, increasing participation in screening and vaccination will be essential for the Netherlands to reduce incidence to below 4 per 100,000 women, in line with the global strategy to eliminate cervical cancer.

graphic file with name IJC-158-39-g003.jpg

Abbreviations

ESR

European Standardized Rates

HPV

human papillomavirus

hrHPV

high‐risk human papillomavirus

NCR

Netherlands Cancer Registry

1. INTRODUCTION

Cervical cancer remains a public health problem globally, ranking as the fourth most common cancer among women and the fourth leading cause of cancer‐related deaths. 1 Most deaths occur in low‐ and middle‐income countries due to limited access to healthcare, preventive strategies, and treatment. In contrast, high‐income countries have seen a decrease in incidence and mortality thanks to better healthcare access and organized screening programs. 2 , 3

In the Netherlands, a steady decline in cervical cancer incidence was reported from 1989 to 2001, due to the implementation of a nationally centered program that invites women aged 30–60 every 5 years. 4 However, an increase in incidence was observed from 2001 to 2007, especially in women aged 35–59. 4

The current report updates the time trends in cervical cancer incidence from 1989 to 2023 in the Netherlands and evaluates whether changes in screening practices or participation rates over the past decades are reflected in these trends. This analysis aims to determine whether fluctuations in incidence align with shifts in policy or clinical practices, providing a more accurate evaluation of intervention effectiveness and offering insights for improving cervical cancer prevention, especially since the Netherlands has joined the global strategy to eliminate cervical cancer, with the goal of reducing incidence to below 4 per 100,000 women. 5

2. METHODS

2.1. Context: historical overview of Dutch cervical cancer prevention

In the Netherlands, cytology has been used on a large scale since the 1970s. 6 However, it was not incorporated into an organized program or systematically offered until the 1980s, when women aged 35–54 were screened triennially. 4 During the 1990s, several studies demonstrated that the program was not cost‐effective due to the high frequency of testing and the limited target age population. 4 , 7 , 8 Consequently, in 1996, the program became national and centrally managed, with the screening interval extended from 3 to 5 years, the target population expanded to include women aged 30–60, among other organizational changes. 6 , 9 In 2006, a new version of the pathology guideline for cervical cytological examination was implemented, with one of the main changes being the introduction of high‐risk human papillomavirus (hrHPV) testing as a triage method for mild and moderate dysplasia cytology results. 10 In 2009, human papillomavirus (HPV) vaccination was initiated with the bivalent vaccine through a catch‐up campaign targeting girls born between 1993 and 1996. 11 From 2010 onwards, vaccination of girls aged 12–13 years was incorporated into the National Immunization Program. 11 However, since 2022, HPV vaccination has been offered to both boys and girls on their 10th birthday. 11 In 2017, hrHPV testing replaced cytology as the primary screening test, including the option of self‐sampling to increase uptake. 6 In March 2020, the screening program was suspended due to the coronavirus disease 2019 (COVID‐19) pandemic but progressively restarted in July 2020. 12 The latest change occurred in July 2022, when HPV genotyping (HPV16/18) in conjunction with cytology was implemented as a triage strategy for HPV‐positive women to better stratify women at risk of high‐grade lesions due to the increased number of false‐positive colposcopy referrals. 13

2.2. Study design and data sources

This ecological study used group‐level data from the Netherlands Cancer Registry (NCR). We retrieved the age group European Standardized Rates (ESR) of all histological types of cervical cancer incidence for the entire country from 1989 to 2023. The retrieved ESR are age‐standardized using the 2010 European Standard Population.

2.3. Age–period–cohort analysis

Age–period–cohort analysis was used to understand observed trends over three temporal dimensions: age, period, and cohort. 14 To visualize these dimensions, the mean ESR per age group was plotted, with the mean ESR always serving as the dependent variable on the Y‐axis, while age and period were the independent variables on the X‐axis. The birth cohort effect was estimated as the interaction between age and period, calculated as the difference: period – age = cohort. When age was displayed on the X‐axis, the mean ESR for each birth cohort and period group was shown. When period was displayed on the X‐axis, the mean ESR for each birth cohort and age group was plotted. The analysis was conducted using R version 4.3.1, with the ggplot2 and dplyr packages.

2.4. Join‐point regression analysis

The mean ESR per period was used to conduct the join‐point regression analysis to identify statistically significant changes in trends over time. This method detects the specific years (Joinpoints) where significant shifts in the incidence occur and calculates the annual percent change for each segment of the trend using a Monte Carlo permutation method. 15 Constant variance was assumed. The analysis was performed using the Joinpoint Regression Program, version 5.2.0. A p‐value of less than .05 was defined as statistically significant.

3. RESULTS

In the Netherlands, cervical cancer incidence (ESR) ranged from 9.4 to 13.8 per 100,000 women between 1989 and 2023, with the lowest rates observed between 2003 and 2015 (Figure S1).

In the age–period–cohort analysis, with age on the X‐axis, a similar pattern was observed among the period group. Incidence increased around age 30, decreased afterward, and rose again after age 60. Among women aged 30–34, the highest incidence occurred in 2019–2023, while for women aged 70–74, the peak incidence was in 1989–1993 (Figure 1A). Analysis by birth cohort showed that women born between 1986 and 1995 had the highest cervical incidence rate (Figure 1B). Among older birth cohorts, incidence declined across successive birth cohorts. For instance, at age 65–69, the incidence was 19 per 100,000 women in the 1916–1925 birth cohort, 12.4 per 100,000 women in the 1926–1935 birth cohort, and further declined to 8.7 per 100,000 women in the 1936–1945 birth cohort (Figure S2B).

FIGURE 1.

FIGURE 1

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Trends of cervical cancer over three temporal dimensions: Age, period, and cohort. (A) Mean cervical cancer incidence rate by age group across different periods. (B) Mean cervical cancer incidence rate by age group across different cohorts. (C) Mean cervical cancer incidence rate by period across different age groups. (D) Mean cervical cancer incidence rate by period across different age cohorts.

When the period was plotted on the X‐axis, incidence among women aged 15–29 remained close to zero from 1989 to 2023. Among women aged 30–39 and 40–49, incidence increased, particularly after 2005. For women aged 40–49 and 50–59, incidence remained stable, while it decreased in women aged 60 or more, dropping from above 15 per 100,000 women in 1989 to below 10 per 100,000 women in 2023 (Figure 1C). Birth cohort analysis showed a decline in incidence among older cohorts (1896–1935) from 1989 to 2023. In contrast, the youngest birth cohorts (1976–1995) showed a sharp increase, with rates rising from below 2.5 per 100,000 women in 2000 to over 20 per 100,000 by 2021 (Figure 1D). Additional stratified results with smaller categories of period group, age group, and cohort group are presented in Figure S2A–D.

Using join‐point analysis, we observed a significant decline in the incidence of cervical cancer from 1989 to 2003, with an annual percent change of −2.3% (95% confidence interval [CI]: −3.3, −1.7; p < .01). From 2003 to 2023, the cervical cancer incidence increases with an annual percent change of 0.6% (95% CI: 0.2, 1.2; p < .005) (Figure 2).

FIGURE 2.

FIGURE 2

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Join‐point analysis of the incidence of cervical cancer from 1998 to 2023, showing a significant annual percent change (APC) decline from 1998 to 2003, followed by a significant annual percent change increase from 2003 to 20. *Indicates that the APC is significantly different from zero at the α = .05 level. Final selected model: 1 join‐point. ESR, European Standardized Rates.

4. DISCUSSION

In this study, we evaluated trends in cervical cancer incidence in the Netherlands over a period of 34 years (1989–2023). Overall, cervical cancer incidence demonstrated several temporal patterns during the study period, with the ESR ranging from 9.4 to 13.8 per 100,000. Age–period–cohort analysis showed the expected bimodal age‐specific pattern, with peaks at ages 30–34 and after 60. Younger cohorts showed an increasing trend in cervical cancer incidence rates, while older cohorts showed a steady decline across generations. Join‐point analysis identified a significant decline in incidence from 1989 to 2003, followed by a significant increase from 2003 to 2023.

The overall incidence of cervical cancer remained relatively low during this period, with the highest recorded rate of 13.8 per 100,000 women in 1990, compared to rates as high as 18 per 100,000 women reported in low‐ and middle‐income countries in 2022. 16 Join‐point analysis showed a decrease in incidence from 1989 to 2003, likely reflecting the impact of the changes made to cervical cancer screening in the Netherlands in 1996, as reported by de Kok et al. 4 The age–period–cohort analysis showed that this decline was primarily driven by older cohorts, where incidence generally decreased across both age and period. This trend was observed in birth cohorts such as 1926–1935, 1936–1945, and 1956–1965, which had the opportunity to undergo multiple rounds of screening. These cohorts benefited from the changes in 1996 (the program became national and centrally managed, with the screening interval extended from 3 to 5 years and the target population expanded to include women aged 30–60), as well as improvements made in 2006 (hrHPV testing was introduced as a triage method for mild and moderate dysplasia cytology primary results), which could be reflected in the overall decreasing trend due to better management of these women. 6 , 9 , 10

The study by de Kok et al. in 2011 also indicated a statistically significant increase in cervical cancer incidence from 2001 to 2007. 4 Our current study including data up to 2023 suggests that this increasing trend has continued, as shown by the results from the join‐point analysis, and it is also a trend reported by NCR. 17 The age–period–cohort analysis showed that the increase was mainly driven by younger birth cohorts (1976–1995), with a rise observed since the 2000s. Notably, the highest incidence in these cohorts was recorded among women who began screening between 2019 and 2023. This increase aligns with the findings reported by van der Horst et al. in 2016, who observed an increase in adenocarcinoma incidence, particularly among younger women from 2004 to 2013, which is consistent with our results from the age–period–cohort analysis. 18 Besides, the implementation of hrHPV testing as the primary screening method in 2017, with significantly higher sensitivity for detecting Cervical Intraepithelial Neoplasia grade 3 or worse (CIN3+) (from ~55% to ~98%), led to the identification of more CIN3+ lesions, likely contributing to the higher incidence observed in women aged 30–34 between 2019 and 2023. 6 It is important to note that the current data cover only the first screening round (2017–2021) and part of the second round (2022–2023) using the hrHPV test as the primary screening tool. A decline in incidence is expected in subsequent rounds, as most CIN3+ are likely to be detected in the first round of the hrHPV‐based screening program. In fact, in Figure 1C, a small decline in cervical cancer incidence can already be observed in 2022 and 2023 across most age groups.

Another factor that could explain these variations in cervical cancer incidence is the participation rate in the national population‐based cervical cancer screening program over time. Overall, participation has decreased throughout the study period. The participation rate before 1994 was 82%, dropping to 77% in 2003. 9 We could not find publicly available data on screening participation between 2004 and 2011. However, from 2012 onward, the Dutch screening monitor reported a participation rate of 65% (2012–2015), dropping to 57% in 2017 after the introduction of HPV‐based screening, and to 50% in 2023. 19 , 20 , 21 Furthermore, in March 2020, the Dutch cervical cancer screening program was suspended due to the COVID‐19 pandemic and gradually restarted in July 2020, with additional measures in October and November 2020, such as sending more invitations to compensate for the participation drop that year. 12 The main reason for the decline in participation appears to be the removal of general practitioners (GPs) from the invitation process in 2017, alongside other well‐known barriers to participation. These include language difficulties and discomfort with the screening procedure—issues that self‐sampling kits and translated invitation letters aim to address. 22 , 23 Efforts to increase participation, including the introduction of self‐sampling kits, the reintegration of GPs into the invitation process, and the sending of more reminders, have been made. 12 , 22 In particular, the use of self‐sampling kits increased from 4.1% in 2017 to 44% in 2023, yet overall participation rates still declined. 19 , 21 This may have also contributed to the rise in cervical cancer incidence observed since 2003.

It is important to note that most European countries have achieved continuous declines in age‐standardized cervical cancer incidence, with the exceptions of the Netherlands and Italy. 24 The Netherlands was the first country to implement HPV testing—initially as a triage following cytology and later as the primary screening test. 25 Consequently, it may be the first in which the full impact of HPV screening becomes evident. Indeed, our results indicate that the recent increase in incidence closely follows the first birth cohorts screened with HPV testing, suggesting a direct link between this policy change and the observed trend.

Although the effects of HPV vaccination cannot yet be assessed in the current data, as the first vaccinated women began entering population‐based screening in 2023, a reduction in incidence is expected. However, it is important to note that participation in the vaccination program in the Netherlands remains relatively low, around 50%. 26

5. CONCLUSION

In conclusion, trends in cervical cancer incidence in the Netherlands suggest a positive impact of the screening program, with a steady decrease over the years. The recent increase in incidence, particularly among younger women, likely reflects the use of a screening test with significantly higher sensitivity (~98%) to detect high‐grade lesions and cervical cancer, as well as reduced participation in screening. However, it is expected that cervical cancer incidence will decrease in the near future due to the national HPV vaccination program, which started in 2009, with the first vaccinated women beginning to participate in population‐based screening in 2023. Additionally, the introduction of the primary HPV screening test with high sensitivity (~98%) in 2017 is expected to identify more premalignant lesions, thus reducing the number of cases that would have progressed to cervical cancer. Nevertheless, efforts should focus on increasing participation in both screening and vaccination, as this is essential to achieving the goal of reducing incidence to below 4 per 100,000 women, in line with the global strategy to eliminate cervical cancer.

AUTHOR CONTRIBUTIONS

Kelly Melisa Castañeda: Conceptualization; methodology; formal analysis; writing – original draft. Karin Marianne Vermeulen: Conceptualization; writing – review and editing. Maaike van der Aa: Conceptualization; formal analysis; writing – review and editing. Ed Schuuring: Conceptualization; supervision; writing – review and editing. G. Bea A. Wisman: Conceptualization; supervision; writing – review and editing. Geertruida Hendrika de Bock: Conceptualization; methodology; project administration; supervision; writing – review and editing.

FUNDING INFORMATION

This work was supported by the Ministry of Science, Technology, and Innovation Ciencias), Colombia (PhD call 860 to Kelly Melisa Castañeda).

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Data S1. Supporting Information.

IJC-158-39-s001.pdf (155.6KB, pdf)

ACKNOWLEDGMENTS

This work is generated within the European Reference Network for rare adult solid cancers (EURACAN).

Castañeda KM, Vermeulen KM, van der Aa M, Schuuring E, Wisman GBA, de Bock GH. Trends in cervical cancer incidence in the Netherlands: A join‐point and age–period–cohort analysis (1989–2023). Int J Cancer. 2026;158(1):39‐44. doi: 10.1002/ijc.70134

DATA AVAILABILITY STATEMENT

The data underlying this article are available in the Netherlands Cancer Registry: https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnkr‐cijfers.iknl.nl%2Fviewer%2Fincidentie‐per‐jaar%3Flanguage%3Den_GB%26viewerId%3Ded34b759‐5350‐4047‐947b‐612436e38295&data=05%7C02%7Ck.m.castaneda.vanegas%40umcg.nl%7Cfa8429f79c08406f5f6f08dd6ba89672%7C335122f9d4f44d67a2fccd6dc20dde70%7C0%7C0%7C638785094003424521%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=UOm3LEG52UztjTEjpHgh1R6hUTveeFQRvR%2F7VbVrB3I%3D&reserved=0. The standardized incidence rates (ESR) and corresponding case counts by calendar year and age groups are also provided in Tables S1 and S2, respectively. Further information is available from the corresponding author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1. Supporting Information.

IJC-158-39-s001.pdf (155.6KB, pdf)

Data Availability Statement

The data underlying this article are available in the Netherlands Cancer Registry: https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnkr‐cijfers.iknl.nl%2Fviewer%2Fincidentie‐per‐jaar%3Flanguage%3Den_GB%26viewerId%3Ded34b759‐5350‐4047‐947b‐612436e38295&data=05%7C02%7Ck.m.castaneda.vanegas%40umcg.nl%7Cfa8429f79c08406f5f6f08dd6ba89672%7C335122f9d4f44d67a2fccd6dc20dde70%7C0%7C0%7C638785094003424521%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=UOm3LEG52UztjTEjpHgh1R6hUTveeFQRvR%2F7VbVrB3I%3D&reserved=0. The standardized incidence rates (ESR) and corresponding case counts by calendar year and age groups are also provided in Tables S1 and S2, respectively. Further information is available from the corresponding author upon request.

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