Cervical Cancer Screening:in

Eastern Europe

Dr. Diana ValutaXII INTERNATIONAL WORKSHOP

OF LOWER GENITAL TRACT PATHOLOGY5-7 March 2015

Primary Objectives:• To prevent disease and death from cervical

cancer-To detect CIN so it can be removed to prevent cervical cancer occurring

• To prevent the side-effects of screening- Stress and inconvenience for the women being screening- Over-diagnosis (false positives)- Over treatment (with the risk of pregnancy complications)

Cervical Cancer Screening

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Screening is a population health action• Applied to hundreds of thousands or

millions of people• Even small harms will have big effects

because of the number of people involved

• More serious harms (such as over-treatment with pregnancy complications) can cause major problems for the people involved and the health care system

Cervical Cancer Screening

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Key Elements to Ensure the Effectiveness of a Screening Program:

1. Access to a database of the entire eligible screening population

2. Direct invitation of women3. Screening and follow-up provided free of charge4. Monitoring of screening and follow-up compliance5. Registration of cytology, histology and cervical

cancers6. Quality control at all levels7. Audit of cervical cancer cases

i.e. A population-based, organised program following the European Guideline for QA in Cervical Cancer Screening

Cervical Cancer Screening

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Cervical Cancer ScreeningCoverage of the target population

Key changes:• Increased coverage• Adherence to recommended screening age range and interval• Effective follow-up and management of screen positive women• Strict quality assurance 5

1–5 Years 5–10+ Years

Cervical Cancer

<90% of HPV infections are cleared with subsequent CIN regression

HPVInfection LSIL-HSIL

Annual screening will detect many lesions that will regress spontaneously

Cervical Cancer ScreeningMaintenance of the screening interval

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420000

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520000

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80&83 84&87 88&91 92&95 96&99 00&03 04&06

Age a

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incid

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of C

C pr

100.0

00 w

omen

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Num

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test

s pr y

ear

Year period (4)

Organised screeningOpportunistic screening

Number of Pap tests

CervicalCancerIncidence

Cervical Cancer Screening

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Recommendations, reports & guidelines supporting the implementation of population-based, organised screening programs:1. European Council recommendation 2003/878/EC on cancer

screening of 3 December 20032. Cancer Screening in the European Union – 2007: Report

on the Implementation of the Council Recommendation within the European Union

3. European Guidelines for Quality Assurance in Cervical Cancer Screening, Second Edition, 2008

4. European Parliament resolution P6_TA(2008)0121 of 10 April 2008 on combating cancer in the enlarged European Union

Cervical Cancer Screening

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Eastern European Contries

Cervical Cancer Rates Across Eastern Europe

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IncidenceMortality

Cervical Cancer Rates Across Eastern Europe

The problem of cervical cancer in Eastern Europe:• Cervical cancer incidence and mortality rates

that are ≤10 times higher than in Western EuropeReasons for the problem:• Limited availability of organized cervical cancer

screening programs• Low coverage rates for both organized and

opportunistic screening• Poor/no quality assurance for both - organized

or opportunistic screening

Cervical Cancer Rates Across Eastern Europe

Zdravka Valerianova1, Yulia Panayotova2, Camilla Amati3, and Paolo Baili3 onbehalf of the EUROCHIP Working Group4

Tumori, 96: 538-544, 2010

• 1970 to 1985 – had population based cervical screening, was pioneer in cervical screening in Eastern Europe

• 1990 - was replaced with an opportunistic model due to political and socioeconomic reasons

• In 2012 the Incidence reached 24,48 per 100 000 population

• 2014 – National Program for NCD (2014-2020) was approved

• 2014 – Cervical Screening pilot programe was started

Cervical screening in Bulgaria - past & present

• Traditionally provided by GPs or medical assistants

• Cervical screening is free for all women of screening age

• Cancer treatment is free for all patients with histologically confirmed diagnosis

• Incidence in 2013 was 16,8 per 100 000 women

• Mortality in 2013 was 10,3 per 100 000 women

Cervical screening in Rep. Moldova - past & present

Pap-smears coverage per year per district

Cervical screening in Rep. Moldova - past & present

What are the issues?• Overall coverage less than 50%• Insufficient training -> poor quality Pap tests• High levels of inflammatory Pap tests (≤40%)• Low capacity of cytology laboratories -> long

reporting times• Romanowsky staining still predominates• Lack of knowledge about the management of Pap

test abnormalities• Lack of specialists certificated in colposcopy• Lack of quality assurance

Cervical screening in Rep. Moldova - past & present

• UNFPA have facilitated the development of cervical screening since 2009 with 6 years of close collaboration and ongoing advocacy

• WHO have facilitated the development the National Cancer Control Strategy and cervical screening was included in the draft of this document.

• ECCA have supported the cervical screening since 2009 with the preparation of a national Capacity Assessment, Recommendations and Action Plan for a National Organized Cervical Screening Program in the Republic of Moldova

• MH and National Health Insurance Fund are now in the process of implementing the Action Plan with ongoing support from the UNFPA, ECCA, Italian colleagues, Irish colleagues, etc.

Cervical screening in Rep. Moldova - past & present

• Oportunistic Screening (preventive exam)• All women aged 18-60 are entitled to annual

cervical screening through PHC services• Ukraine does not have Mandatory Health

Insurance• The follow-up to abnormal screening tests, as

well as the treatment of CIN are not free of charge• No quality assurance mechanisms in place• National Programme for Fighting Cancer for the

2014-2020 period was approved – but this did not include anything about an organized cervical cancer screening program

Cervical screening in the Ukraine - past & present

• 2005 - National Population-Based Cervical Cancer Screening Program was developed (MoH, the National Health Fund and the Polish Gynecological Society following WHO/IARC guidelines)

• Its implementation started in 2006.

• Incidence: decreased from 2005-2010 with 5,7% In 2012 was 12,19 per 100 000 female population

• Mortality: decline with 3,4% in the same period of timeIn 2012 was 5,43 per 100 000 women

Cervical screening in Poland - past & present

• The target population are women aged 25 to 59 insured in the National Health Fund.

• The Pap test is done with a three-year interval, free of charge.• The system is based on personal invitations, sent by regular

post.• The NHF data base enables identification of women to

screen.• Pap smears are collected by gynecologists and since 2008 also

by midwives trained and certified by the Program.• Pap test results are reported in the Bethesda 2001 system. • SIMP (System of Information Monitoring in Prophylaxis)

with online access to all records was developed. • The Screening Program has its system of quality assurance.

Cervical screening in Poland - past & present

The common problems for Eastern Europe countries

• Absence of a health policy/strategy on screening

• Absence of an organized population-based screening

• Lack of human resources and capacities of health professionals in screening

• Inefficient use of financial resources

• Absence of a screening register

• Unwillingness of women to be screened

• Obstacles in covering all eligible women

• Existing cytological laboratories do no respond to the needs of an organized screening programme

Recommendations Reports & Resolutions

Guidelines

Lobbying & Advocacy

Increased Political

Will

Implementation of Population-Based

Organised Screening programs

The common solutions for Eastern Europe countries

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Together we can win

Thank you for your attention