Transcript Slide 1

Cervical Cancer Screening
Assessment in RomaniaProblems, Present, Future
Iuliana Apostol, MD
Dr Victor Babes Foundation,
Bucharest, Romania
Epidemiological Data
Epidemiological Data
National Epidemiological Data
Source: CCSS
Age-specific rates of the incidence of cervical cancer in
females in Romania over the period 1998 - 2003
100.00
80.00
1999
70.00
2000
60.00
50.00
2001
2002
40.00
2003
30.00
20.00
10.00
Age-group
+
85
-8
4
80
-7
9
75
-7
4
70
-6
9
65
-6
4
60
-5
9
55
-5
4
50
-4
9
45
-4
4
40
-3
9
35
-3
4
30
-2
9
25
-2
4
20
4
-1
9
15
-1
-9
10
5
4
0.00
0-
Age-specific rates
90.00
National Epidemiological Data
Source: CCSS
Crude and age-standardised rates of the incidence of
cervical cancer in Romania
35.00
30.00
25.00
20.00
15.00
CR
10.00
ASR
5.00
0.00
1999
2000
2001
2002
2003
National Epidemiological Data
Source: CCSS
Age-specific rates of the mortality of cervical
cancer in females in Romania over the period
1999 - 2003
50.00
1999
2000
45.00
40.00
2001
30.00
2002
25.00
2003
20.00
15.00
10.00
5.00
Age-group
85
+
75
-7
9
80
-8
4
65
-6
9
70
-7
4
55
-5
9
60
-6
4
45
-4
9
50
-5
4
35
-3
9
40
-4
4
25
-2
9
30
-3
4
15
-1
9
20
-2
4
-1
4
10
5
-9
0.00
04
Rates
35.00
National Epidemiological Data
Source: CCSS
Crude and age-standardised rates of the mortality
of cervical cancer in Romania
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
ASR
CR
1999
2000
2001
2002
2003
Why These Epidemiological Figures ?
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Romanian Statistic Annual 2004:
Cervical cancer incidence =33,88:100.000 women
Cervical cancer mortality =16,38:100.000 women
The highest rates (first place) in Europe regarding
specific mortality (CC)
1981-The Commission of Oncology from the Health
Ministry; 1981-1985 the first preventive cancer
strategy.
1986-1990,1991-1995, 1996-2000: successive
preventive cancer strategies, but not finalized (bad
management, frequent changes in high-level
management, inconstant financing).
PAST IN ROMANIA
Organized Screening
 1998-2000 the first pilot study in Cluj district - run
by IOCN.
 2001-2002 the second pilot study for cervical
cancer in Bucharest (3 out of 6 areas) and
neighboring rural areas - run by CPSS.
 2002-2004 a screening program for cervical
cancer in Cluj district - run by IOCN.
1998-2002 The Pilot Studies

First pilot study - in Cluj district: planning and
implementing an organized CC prevention program;
it demonstrated the efficiency of primary medicine in
CC prevention.
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Second pilot study - in Bucharest and neighboring
rural areas: an estimated 40.000 women PAP
tested; developing guidelines for GPs and other
specialists, I & E campaigns, screening activities
and organizing reference centers.
The Best Screening: 2002-2004
 Women aged 25-65, screened with PAP test at
three year interval, in Cluj district.
 Results:
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Built up the screening network at the primary
medicine level; GPs – key providers in the
network.
Elaborated the methodology and quality standards
for the screening program.
Organized a reference cytology laboratory (with
45.000 pap smears).
Set up a regional registry for cervical cytology (a
computerized informational system).
PRESENT IN ROMANIA
Screening at present time
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2005-2006 opportunistic screening for CC, through
the national subprogram of the Health Ministry.
The subprogram 2.2: “Prevention and Control in
Oncology”.
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2005-2006 a regionally organized screening for
CC, through another project: “A model for early
detection of genital-urinary cancer”. It has been
financed by JSI Research & Training Institute,
USA.
The National Oncology Subprogram
 Objective: early detection (stages 0, I, II) of
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cervical cancer cases. The monitoring of the
program is done through the two national
institutes: IOB and IOCN.
Physical indicators: number of screening tests
=32.400.
Efficiency indicators =medium cost/screening test
=10 Euro.
Result indicators: cancer mortality target-decrease
under 197/100.000; proportion of early detection
through screening-increase by 3%.
A Regionally Organized Screening
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The target group: 3.500 women from rural areas,
aged 25-65, from 4 districts and Cluj city.
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The objectives: increase the accessibility of
women from rural areas to the preventive
strategies and increase awareness of the
importance of this examination (I & E campaign).
COMPONENT 1- Community
Information and Education
I & E Activities in the Community
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There are only regional campaigns of I &E
regarding CCP in Romania, limited in time and
most focusing on urban areas; there is only one
regional project with rural focus, regarding the
importance of CCP.
A national survey study -”Reproductive Health
Survey in Romania in 2004” - indicated a low
impact of I & E campaigns.
I & E Activities in the Community
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Attitudes regarding own health: 80% of sexually
active women have never been tested with PAP
smear and 37% never heard of it.
Women that never heard about PAP smear: low
educational level (62%), low socio-economic
status (60%), women with three or more children
(56%), younger women (53% between 15-24
years), rural women.
Source: Final report of Reproductive Health Survey in Romania 2004, a national
study.
I & E Activities in the Community
 Success of this component requires good
selection of important stakeholders, experienced
in training of formulators and involving them into
the new CCP. Broadcasting information through
the mass media, combined with personal
invitation to the screening are the single most
important means of attaining high coverage.
 The new program needs designing and large
dissemination of informative materials, adapted
to the target population, in order to increase the
impact of I&E campaigns.
INVITATION LEAFLET & POSTER
PAPER ADD
COMPONENT 2- Screening
Services
Screening Services - policy
Some changes in health policy are needed:
 Organizing a GP centered program.
 Setting up a unique cervical cancer screening
guide, adapted to the international standards.
 Setting up the desired covering and the frequency
of screening test.
 Reducing ambiguous policies and incompatibilities
between Health Ministry (organization and service
providing) and CNAS (financing) regarding CCP.
Screening Services – Role of GPs
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GPs activities inside the screening services are:
cartography, active recruitment, screening tests,
patient files & reports, communication of test
results.
The best covering can be obtained only through
active intervention of GPs in the patients
recruitment process for the screening.
The program needs some financial incentive for
GPs.
Screening Services - Limitations
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Currently no active recruitment of eligible women
takes place; the process needs to involve GPs as
key providers of services and also better media
dissemination.
There is no unique PAP smear processing and
interpretation in Romania.
There is no unique model for registration of data in
screening process at national level.
There are not enough GPs properly trained for CCP;
a tremendous need for specific training.
Screening Services - Limitations
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There are few resources in a GP’s office, imposing an
important financial limitation to high attendance.
There are no monitoring and evaluation indicators for
the screening services; mandatory: constant
evaluation of the proportion of dysplasia or cancer
detected, false positive and false negative readings.
European Guidelines for Quality Control in Cervix
Cancer Screening must be implemented.
Screening Services - Covering
50
45
40
35
30
25
20
15
10
5
0
18
1993
11.8
1999
16.4
2004
Source: Final report of Reproductive Health Survey in Romania 2004proportion of women with the PAP smear in the last 3 years
Screening Services-publications
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IOB & IOCN Institutes are the leaders in the design
of clinical national guidelines in CC screening.
The existing guidelines need continuous updating.
It is necessary to use the latest version of
international guidelines in CC screening in order to
have only one national model for collecting, storing,
transportation and interpretation of PAP smears (e.g.
implementation the Bethesda system).
PUBLICATIONS CPSS : CD-ROM &
VIDEO RECORDING
PUBLICATIONS CPSS-CERVICAL
CANCER SCREENING GUIDELINE
PUBLICATIONS-IOCN
Screening Services - burden for GPs
1 GP has 1.700 patients, of which approximately
600 women targeted (33%) who need to be
tested each year.
Testing of all 600 women in a year necessitates
roughly 2 hours/daily X 2 times weekly of GP’s
working time, considering a screening test of
15 min/test.
Source: Cervical cancer screening: from theory to practice, national
Conference of Family Practice, Calimanesti, Oct 2002; Teresa Franciuk,
C. I. Chirciu.
COMPONENT 3- Diagnosis
And/ or Treatment Services
Diagnosis and/or Treatment
Services
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Not sufficient linkage between GPs and diagnostic
and histopathology laboratories; no adequate
reference & feedback .
Not enough information about the reference centers
in CCP, no databases.
No generally accepted monitoring and evaluation
indicators for these services.
No qualitative guidelines for the services provided
and a need for continuous training for pathologists
and gynecologists.
Conclusions –things to do
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Obtain policy agreement from
central authorities and implement
policy changes.
Contact central institutions (MoH,
CNAS, INS) and also territorial
institutions (DJSP, CJAS, IJS) to
promote the program.
DJSP contact GPs from territory,
managers of cytology laboratories
and diagnostic & treatment
centers (gynecology, oncology,
histopathology laboratories).
Conclusions - things to do
(cont’d)
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MoH: validate the updated clinical guidelines for CCP
program; organize the training plan for GPs &
specialists; set up a guide for quality control and
accreditation of laboratories/centers, which
participate into the CCP program.
DJSP: disseminate the guide for CCP to GPs &
specialists; plan the educational sessions for GPs and
specialists; evaluate the quality of services provided
in territory.
CNAS estimates the necessary equipment, materials
and also incentives for GPs involved in screening;
CJAS verifies the costs associated with CCP
program.
Conclusions - things to do
(cont’d)
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Set up & analyze system indicators: for
infrastructure - databases with GPs office, cytology
labs, diagnosis and treatment centers; economicestimates of the consumables and costs; outcome
measure -% of reducing invasive cancer.
Set up & analyze human resources indicators:
number of GPs/ specialists trained, number of I&E
campaigns, quantity & type of informative
materials.
Set up & analyze target group indicators: number
of eligible persons, coverage, number of screening
tests, number of FP or FN tests, number of TP tests
(cases of dysplasia/cancer identified).
THANK YOU