IARC’s CERVICAL CANCER SCREENING PROGRAMME

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IARCs CERVICAL CANCER SCREENING PROGRAMME
R. Sankaranarayanan MD Screening Group World
Health Organization International Agency for
Research on Cancer, Lyon, France
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IARCs CERVICAL CANCER SCREENING PROGRAMME
OBJECTIVE
To guide public health policies on cervical
cancer control in different regional, national
and sub-national settings
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IARCs CERVICAL CANCER SCREENING PROGRAMME
Evaluates the role of cytology and various
non-cytology based screening in the early
detection and prevention of cervical neoplasia
world-wide
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IARCs CERVICAL CANCER SCREENING PROGRAMME
SCREENING TESTS EVALUATED

• Conventional cervical cytology
• Unaided visual inspection (downstaging)
• Naked eye visual inspection with 3-5 acetic acid
  (VIA)
• Visual inspection with acetic acid using
  low-level (2-4X) magnification (VIAM)
• Visual inspection with Lugols iodine (VILI)
• HPV testing

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IARCs CERVICAL CANCER SCREENING PROGRAMME
SCREENING APPROACHES EVALUATED

• Low-intensity screening(once a life-time)
• Screen, triage, treat approaches with aposteriori
  histology (1- or 2-visit approach)

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IARCs CERVICAL CANCER SCREENING PROGRAMME
EVALUATION OF TREATMENT OF CERVICAL PRECANCERS

• Cryotherapy by nurses
• LEEP by mid-level clinicians

LEEP (LLETZ)
Cryotherapy
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IARCs CERVICAL CANCER SCREENING PROGRAMME
STUDY DESIGNS

• Cross-sectional studies
• Follow-up (cohort) studies
• Non-randomised controlled trials
• Cluster-randomised controlled trials
• Randomised trials
• Demonstration programmes

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IARCs CERVICAL CANCER SCREENING PROGRAMME
OUTCOMES STUDIED

• Accuracy
• Reproducibility
• Detection rates of CIN/Ca
• Cure rates of CIN
• Side-effects and complications of Rx of CIN
• Stage-distribution
• Reduction in incidence/mortality
• Determinants of participation

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IARCs CERVICAL CANCER SCREENING PROGRAMME
STUDY LOCATIONS
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IARCs CERVICAL CANCER SCREENING PROGRAMME
COLLABORATING INSTITUTIONSAFRICA, EUROPE AND
SOUTH AMERICA

• Maternity Hospital, Luanda, and MOH, Angola
• University Hospital, Ouagadougou, Burkina Faso
• University Hospital, Brazzaville, Republic of
  Congo
• University Hospital, Conakry, and MOH, Guinea
• Hospital Point G, Bamako, Mali
• University Hospital, Nouakchoutt, Mauritannia
• Medical College, Ibadan, Nigeria
• University Hospital, Niamey, Niger
• Ocean Road Cancer Institute, Dar es Salaam,
  Tanzania
• Regional Office of the WHO, Arican Region (AFRO)
• Hospital Edouard Herriot, Lyon, France
• Centre Leon Berard, Lyon, France
• University Hospital, Grenoble, France
• INCTR, Brussels, Belgium
• Health Economics Research Centre, University of
  Oxford
• National Cancer Institute, Lima, Peru
• National Cancer Institute, Bogota, Columbia

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IARCs CERVICAL CANCER SCREENING PROGRAMME
COLLABORATING INSTITUTIONS INDIA

• Tata Memorial Centre, Mumbai,
• Nargis Dutt Memorial Cancer Hospital, Barshi
• Christian Fellowship Community Health Centre,
  Ambillikai
• Regional Cancer Centre, Trivandrum
• Chittaranjan National Cancer Institute, Kolkata
• Cancer Foundation of India, Kolkata
• Cancer Institute (WIA), Chennai
• All India Institute of Medical Sciences, New
  Delhi
• Bhagwan Mahaveer Cancer Hospital Research
  Centre, Jaipur
• PSG Institute of Medical Sciences and Research,
  Coimbatore
• Christian Medical College, Vellore
• Malabar Cancer Care Society, Kannur
• MNJ Cancer Institute, Hyderabad
• Institute for Rural Health Studies, Hyderabad

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IARCs CERVICAL CANCER SCREENING PROGRAMME
COLLABORATING INSTITUTIONS

• BP Koirala Memorial Cancer Hospital, Bharatpur,
  Chitwan, Nepal
• Bhakthapur Cancer Care Centre, Bhakthapur, Nepal
• Nepal Network for Cancer Treatment Research,
  Banepa, Nepal
• University Hospital, Vientiane, Laos
• National Cancer Institute, Bangkok, Thailand

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IARCs CERVICAL CANCER SCREENING PROGRAMME

• 300,000 women in 11 countries
• 38 Institutions in 5 continents
• 436 investigators and workers

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IARCs CERVICAL CANCER SCREENING PROGRAMME
CROSS-SECTIONAL STUDIES OF ACCURACY TO DETECT CIN
2-3 LESIONS
56,939 women
22,633 with cytology 18,085 with HPV testing/HCII
54,918 tested with VIA 16,900 withVIAM 49,080
with VILI
56,939 had colposcopy
9590 had biopsy
3369 CIN 1   1063 CIN 2 3   269 Cx Cancers
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IARCs CERVICAL CANCER SCREENING PROGRAMME
ACCURACY OF SCREENING TESTS
Int J Cancer 2004 110-907-13 J Med Screening
2004 1177-84 Int J Cancer 2004 (in press)
Cancer Detect Prev 2004 (in press)
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Cluster Randomised Controlled Trial of VIA
Screening, Dindigul District, India
Christian Fellowship Community Health Centre
(CFCHC), Ambillikai, India PSG Institute of
Medical Sciences and Research (PSGIMSR),
Coimbatore, India Cancer Institute (WIA),
Chennai, India World Health Organization-Internati
onal Agency for Research Cancer (WHO-IARC), Lyon,
France
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DINDIGUL RCT OF VIA SCREENING, INDIA
Flow chart of the design and preliminary results
of the study
Sankaranarayanan et al., Int J Cancer 109,
461-467 (2004)
PYO person years of observation CR crude
incidence rate ASR age-standardized incidence
rate CIN cervical intraepithelial neoplasia
Percentages refer to proportion of screened women
(N30,577) except for treatment where they refer
to lesion detected
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Comparative efficacy of visual inspection with
acetic acid, HPV testing and conventional
cytology in cervical cancer screening a
randomized intervention trial in Maharashtra
state, India
Tata Memorial Centre (TMC), Mumbai, India Nargis
Dutt Memorial Cancer Hospital (NCMCH), Barshi,
IndiaInternational Agency for Research Cancer
(WHO-IARC), Lyon, France
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FLOW CHART OF THE STUDY DESIGN AND FINDINGS
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OSMANABAD RCT OF CERVICAL SCREENING, INDIA
STAGE DISTRIBUTION OF INVASIVE CANCER IN THE
STUDY ARMS
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OVERTREATMENT IN SCREEN, SEE AND TREAT APPROACH
OSMANABAD AND DINDIGUL DISTRICT SCREENING
PROJECTS, INDIA
Supported by the ACCP through the Bill Melinda
Gates Foundation
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HOW EFFECTIVE ARE THE TREATMENT OF PRECANCERS IN
THE DEVELOPING WORLD?
Cryotherapy Data from Indian studies
LEEP Data from Indian studies
Overall 1 cure rate in CIN 89 (1892/2130)
Supported by the ACCP through the Bill Melinda
Gates Foundation
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IARCs CERVICAL CANCER SCREENING PROGRAMME
EFFICACY OF SINGLE- VS DOUBLE-FREEZE CRYOTHERAPY

• 300 women with CIN randomized
• Preliminary findings indicate same efficacy 89
  NED at 1-year

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IARCs CERVICAL CANCER SCREENING PROGRAMME
TRAINING QUALITY ASSURANCE
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IARCs CERVICAL CANCER SCREENING PROGRAMME
TRAINING MATERIALS
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IARCs CERVICAL CANCER SCREENING PROGRAMME
DETERMINANTS OF PARTICIPATION IN SCREENING

• Low SES
• Low income
• Education
• Parity
• Contraceptive practice

Sankaranarayanan et al., Cancer Detect Prev 2003
27 457-65
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IARCs CERVICAL CANCER SCREENING PROGRAMME
COST EFFECTIVENESS STUDIES
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Unit costs of intervention in Osmanabad district
cervical cancer screening project
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Costs per CIN 2/3 detected in Osmanabad district
cervical cancer screening project
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IARCs CERVICAL CANCER SCREENING PROGRAMME
TRAINING CENTRES

• Chittaranjan National Cancer Institute, Kolkata,
  India
• Regional Cancer Centre, Trivandrum, India
• University Hospital, Conakry, Guinea
• Maternity Hospital, Luanda, Angola
• Ocean Road Cancer Institute, Dar es Salaam,
  Tanzania
• Instututo de Enfermedades Neoplasicas, Lima Peru
• National Cancer Institute, Bogota Columbia

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IARCs CERVICAL CANCER SCREENING PROGRAMME
SCREENING VS EARLY CLINICAL DETECTION

• Awareness
• Test
• Recall
• Follow-up

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Volume 10
Cervix Cancer Screening
2004(in press)
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IARCs CERVICAL CANCER SCREENING PROGRAMME
SUPPORTED BY

• The Bill Melinda Gates Foundation through the
  ACCP
• WHO-AFRO
• International Network for Cancer Treatment and
  Research (INCTR)
• International Union Against Cancer (UICC)
• Association for International Cancer Research
  (AICR)
• Program for Appropriate Technology in Health
  (PATH)