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WHOs cervical cancer screening programmes: managerial guidelines

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Title: WHOs cervical cancer screening programmes: managerial guidelines


1
WHOs cervical cancer screening programmes
managerial guidelines
  • by
  • Naila Baig Ansari
  • Research Fellow
  • Dept. of Community Health Sciences
  • The Aga Khan University
  • Karachi, Pakistan

2
Who am I?
  • Education
  • MSc (Epidemiology), The Aga Khan University,
    2001. Thesis Care and feeding practices and
    their association with stunting among young
    children residing in Karachi-s squatter
    settlements
  • BBA (Management), The College of William and
    Mary, Williamsburg, VA, USA, 1989
  • Research interest Nutritional and behavioral
    epidemiology, methodological issues in dietary
    assessment methods, household food security and
    gender-related issues, care and feeding
    practices, management of data and questionnaire
    designing

3
Learning Objectives
  • To understand the importance of establishing a
    cervical cancer screening programme
  • To be familiar with the WHO recommended
    managerial factors to consider prior to setting
    up a screening programme
  • To understand the concept of downstaging in
    terms of cervical cancer screening

4
Performance Objectives
  • Know the managerial issues to consider when
    setting up a cervical screening program
  • Understand the concept of downstaging and
    possible approaches of downstaging cervical
    cancer

5
Introduction
  • Cervical cancer is the 2nd most common cancer
    among women globally
  • Higher cervical cancer mortality in developing
    countries due to lack of effective screening
    programs

6
Introduction
  • High proportion of women are diagnosed at an
    advanced stage due to
  • Lack of knowledge among women of the relevance of
    symptoms
  • Fatalistic attitude towards cancer and
    possibility of being cured
  • Lack of availability of health care in rural
    areas
  • Low priority of womens health issues

7
Managerial factors to consider when setting up a
screening programme
  • Formulation of screening programmes
  • The natural history of cervical cancer
  • Implications of screening policy
  • Service delivery
  • Information systems
  • Programme evaluation
  • Downstaging where cytological screening not
    possible

8
Natural History
  • Cervical cancer develops slowly, and the key
    precursor is severe dysplasia. The natural
    history begins with
  • the onset of sexual activity at about age 13,
  • cervical dysplasia appears about age 18 through
    35 years
  • Carcinoma in situ begins about age 35 years
    through to about age 50 when invasive cancers
    begin to appear as a prelude to death at about
    age 55.

9
Risk Factors identified
  • Human papillomavirus (HPV DNA is present 93 of
    cervical cancer and its precursor lesions)
  • Epidemiologic studies ongoing on cofactors and
    host factors that may explain the natural history
    of HPV infections and their associated lesions.
  • Factors under investigation include smoking use
    of hormonal contraceptives number of live
    births young age at first sexual intercourse
    use of vitamins such as carotenoids, vitamin C,
    and folic acid co-infection with other sexually
    transmitted diseases (e.g., herpes simplex, HIV,
    chlamydia) growth factors

10
Implementation and evaluation of cervical
screening
  • Decision to implement screening for cervical
    cancer should be based on
  • Evidence that cervical cancer is a major health
    problem
  • Characteristics of individuals and populations at
    risk
  • An appropriate health service infrastructure
  • Technical resources for smear collection and
    cytological examination
  • Resources for diagnosis and treatment

11
Which health service sector?
  • Decision on which health service sector to
    utilize for screening based on
  • Epidemiology
  • Coverage of women at risk
  • Use of maternal and child health /
    family-planning services
  • Occupational health services
  • Mobile units of screening
  • Cost of screening in different health sectors

12
Frequency of screening
  • Women with negative cervical smear have low rates
    of invasive cancer for 5 years. Also rates below
    those in general population for 10 or more years
  • Cost-effective approach to recruit high
    proportion of the population and screen them
    infrequently rather than low proportion and
    frequent screening

13
Estimated reduction in the cumulative incidence
of invasive cervical cancer in Chile as a result
of a single screen at various ages
14
Cost-effectiveness of two different strategies
for cervical cancer screening in Chile
15
Screening in Primary Health Care
  • Setting up a screening service
  • Target group
  • Ensuring target group is screened
  • Recording and reporting
  • Management of women with abnormal smears

16
What is downstaging for cervical cancers
  • Downstaging is the detection of the disease in
    the earlier stage when still curable, by nurses
    and other non-medical health workers using a
    simple speculum for visual inspection of the
    cervix

17
Possible approaches to downstaging for cervical
cancer
  • Health education
  • Restrict examination to women over 35 years
  • Train female primary health workers to examine
    the cervix visually and to identify abnormalities
  • Establish a link between identification of an
    abnormality and referral

18
Example of process and impact measures to monitor
and evaluate downstaging
  • Process Measures
  • More than 80 of women in the 35-50 year target
    group are educated on cervical cancer.
  • More than 80 of primary health workers are
    educated and trained in visual examination of the
    cervix.
  • Impact Measures
  • Over 80 of women in the target 35-50 year group
    are examined at least once.

19
Example of outcome measures to monitor and
evaluate downstaging
  • Outcome Measures
  • Short Term More than one-third of cervical
    cancers are discovered by examination
  • Medium Term There is more than a third reduction
    in cases presenting with advanced disease
    (Stage II and beyond).
  • Long Term There is more than a third reduction
    in the mortality of cervical cancer.

20
Cancer Control Program
  • A cancer control program is like a chair with
    four legs, a seat and a back.
  • Four legs represent interventions or programs
    of prevention, screening, treatment and
    palliation.
  • Seat joins the four legs into a functional chair.
    It represents the organizational structure,
    management and governance of a national cancer
    control program that integrates its four programs
    into a functional unity.
  • Back of the chair provides support. Represents
    the infrastructure that needs to be in place for
    the four programs to function.

21
Online sources of interest
  • The Merck Manual of Diagnosis and Therapy,
    Section 18. Gynecology And Obstetrics Chapter
    241. Gynecologic Neoplasms
  • Cervical Cancer Screening Training Modules
  • MedlinePlus Health Information on cervical cancer
  • Reproductive Health Outlook (RHO) cervical
    cancer
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