Cervical screening under wartime: resilience and quality of laboratory services in Ukraine during the Russian invasion

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Introduction Since February 2022, Ukraine has been facing the challenges of active armed conflict, undermining its healthcare system. Despite the ongoing war, the national cervical cancer screening program was launched in 2025. However, little is known about whether laboratory diagnostic quality can be maintained under these conditions. This study aimed to assess the resilience of cervical cancer screening services in Ukraine during wartime by evaluating the temporal dynamics of PAP smears, HPV testing, and their quality indicators. Materials and methods This single-center, repeated cross-sectional study included laboratory data collected on PAP smears from 946,451 cases and 114,974 HPV tests retrieved from the database of the Medical Laboratory CSD in 2021–2025. The Annual Bethesda System 2014 (BS 2014) category proportions and quality metrics (including the ASC/SIL ratio and non-diagnostic rate) were assessed and compared with the benchmarks from BS 2014 and the College of American Pathologists (CAP). HPV testing data included overall positivity rates and HPV 16/18 genotype distribution. Results The volume of PAP tests decreased by 21.5% in 2022; however, there was a significant recovery in 2023, with an increase of 85.3% in 2025 compared to the pre-war baseline (2021). Each Bethesda category proportion for every year aligned within international benchmark ranges. The five-year CSD medians were as follows: NILM—91.27% (89.24–91.61%); ASC-US—4.45% (3.94–5.38%); LSIL—2.83% (2.49–3.57%); HSIL—0.38% (0.31–0.62%), non-diagnostic—0.80% (0.54–1.03%); SCC—0.024% (0.016–0.051%); and AGC—0.25% (0.22–0.26%). Quality metrics were consistent with global reference values, with a total abnormal sample rate of 7.81% (7.7–9.67%), ASC/SIL ratio of 1.36 (1.18–1.66), and ASC-US/LSIL ratio of 1.47 (1.28–1.79). HPV testing expanded at a disproportionately higher rate than Pap test utilization, surging 27.8-fold over the wartime period. HPV positivity declined significantly from 21.07% in 2021 to 17.16% in 2025 ( p = 0.011). While HPV16 prevalence remained relatively stable, the relative contribution of HPV18 nearly doubled, rising from 5.6 to 10.4% among HPV-positive individuals ( p = 0.008). Conclusion Cytopathological reporting patterns remained within benchmark ranges under 4 years of armed conflict in Ukraine, with diagnostic performance of CSD LAB corresponding to international benchmarks. The rapid HPV testing expansion associated with an increased rate of testing among younger women, a decline in HPV positivity among the 30–65 cohort, and a rise in the HPV 18 proportional rate have direct implications for national vaccination and screening policies.

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