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Periodic screening for breast and cervical cancer in women with diabetes: a population-based cohort study

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Diabetes is associated with poorer cancer outcomes. Screening for breast and cervical cancer is recommended by clinical guidelines; however, utilization of these tests in people with diabetes has been unclear due to methodological limitations in the evidence base. We used administrative data to determine the association between diabetes and the rates of becoming up-to-date with periodic breast and cervical cancer screening over a 20-year period.


Healthcare databases from Ontario, Canada, were linked to assemble two population-based cohorts of 50–70 and 21–70 year-olds between 1994 and 2011, eligible for breast and cervical cancer screening, respectively. Using age as the time scale, multivariable recurrent events models were implemented to examine the association between the presence of diabetes and the rates of becoming up-to-date with the recommended cancer screenings.


In each of the breast and cervical cancer screening cohorts, there were, respectively, 1,516,302 (16% had diabetes at baseline) and 4,751,220 (9.5% had diabetes at baseline) screen-eligible women. In multivariable models, prevalent diabetes (duration ≥ 2 years) was associated with lower rates of becoming up-to-date with cervical (hazard ratio, HR 0.85, 95% confidence interval, CI 0.84–0.85) and breast (HR 0.94, CI 0.93–0.94) cancer screening, compared to no diabetes.


Having diabetes is associated with decreased rates of becoming up-to-date with two recommended periodic cancer screenings, with a bigger reduction in the rates of becoming up-to-date with cervical cancer screening. Greater attention to cervical cancer preventive services is needed in women with diabetes.

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Data availability

The dataset from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at The full dataset creation plan and underlying analytic code are available from the authors upon reasonable request, understanding that the programs may rely upon coding templates or macros that are unique to ICES.


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We thank Hadas Fischer and Kinwah Fung for their assistance with study design and data collection. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed in the material are those of the author(s), and not necessarily those of CIHI. Parts of this material are based on data and information provided by Ontario Health-Cancer Care Ontario (CCO). The opinions, results, views, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of CCO. No endorsement by CCO is intended or should be inferred. Parts of this material are based on data from Immigration, Refugees and Citizenship Canada (IRCC). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement by any of the funding or data sources is intended or should be inferred. DB is supported by the Helen Marion Walker Soroptimist Women’s Health Research Scholarship from Women’s College Hospital and Soroptimist International. LLL is supported by the Diabetes Investigator Award from Diabetes Canada. PCA is supported by a Mid-Career Investigator award from the Heart and Stroke Foundation. LFP is supported by a clinician-scientist award from the Ontario Ministry of Health.


This study was funded by a grant from the Ontario Institute for Cancer Research (OICR) and the Canadian Institutes for Health Research (CIHR) (grant #123263). The funder had no role in the design of the study, in the collection, analysis and interpretation of the data, or in writing the manuscript.

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The corresponding author attests that all listed authors meet authorship criteria and that no others have been omitted. All authors had full access to the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. The senior author (Dr. Lorraine L. Lipscombe) is the guarantor of this work.

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Correspondence to Dominika Bhatia.

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This study complied with the ICES data privacy guidelines and was approved by the ICES Privacy and Legal Office. ICES is an independent, non-profit research institute that is a prescribed entity under section 45 of Ontario’s Personal Health Information Protection Act, which authorizes ICES to collect personal health information, without consent, for the purposes of health system analysis. By definition, studies conducted under section 45 do not require approval by an institutional research ethics board.

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Bhatia, D., Sutradhar, R., Austin, P.C. et al. Periodic screening for breast and cervical cancer in women with diabetes: a population-based cohort study. Cancer Causes Control 33, 249–259 (2022).

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