Cervical Cancer Screening Strategies for Developed and Developing Countries

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Cervical Cancer Screening Strategies for
Developed and Developing Countries

• Kunter Yüce M.D
• Hacettepe University Medical Faculty Dept Ob /
  Gyn
• Professor, Head of Gynecologic Oncology
• President of Turkish Society for Colposcopy and
  Cervical Pathology
• Member at Large EFC

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Global Burden of Cancer (2008)
12.68 million new cancer cases worldwide (5.58 in
more developed regions, 7.10 in less developed
regions)
7.57 million cancer deaths worldwide (2.75 in
more developed regions, 4.82 in less developed
regions)
IARC, GLOBOCAN 2008
3
Proportion of Deaths in the EU due to Cancer in
2006
Women N 2.407.298
Cancer 23
Other 32
Circulatory disease 45
4
Cases and deaths of Breast,Cervical and
Colorectal Cancer in the UE in 2006
Cases
Deaths
Women N 536.700
Women N 1.087.200
Colon and rectum 13
Colon and rectum 13
Breast 17
Breast 30
Cervix 3
Cervix 3
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Global cancer new cases
IARC, GLOBOCAN 2008
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Global cancer - deaths
IARC, GLOBOCAN 2008
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The Most Frequent Cancers In Women Worldwide (In
Thousands Of New Cases / year)
IARC, Globocan 2008
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The Most Frequent Cancers In Women Worldwide (In
Thousands Of New Cases Per Year)
Developing
Developed
691
692
Breast
232
338
Colon/Rect
453
77
Cervix Uteri
272
242
Lung
247
102
Stomach
145
142
Corpus Utery
186
40
Liver
125
100
Ovary
Thyroid
89
74
71
85
N-H lymphoma
138
18
Oesophagus
93
62
Leukaemia
52
81
Pancreas
71
40
Brain, Nervous S.
35
68
Kidney
15
Melanoma of skin
82
64
29
Lip, Oral cavity
IARC, Globocan 2008
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The most frequent cancers in Europe women
7
7
IARC, Globocan 2008
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According to 2008 estimates of the International
Agency for Research on Cancer

• Breast Cancer
• 424,755 cases
• 128,770 deaths
• Cervical Cancer
• 54,323 cases
• 25,102 deaths
• Colorectal cancer
• 202.248 cases
• 101.670 deaths

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Key aspects of implementation of cancer screening
programmes

• Adherence to EU quality assurance guidelines
• Full information of participants about benefits
  and risks
• Adequate comprehensive care for screen-positives
• Adequate human and financial resources for
  organization and quality control
• Informed programme implementation decisions
  (based on disease burden, health care, resources,
  side-effects, cost effects, scientific trials and
  pilot projects)
• Call/recall system and effective diagnosis,
  treatment and aftercare
• Due regard to data protection

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Registration and management of screening data

• Centralised data systems for running programmes
• Call/recall system to invite all the target
  population
• Data collection, management and evaluation for
  test performance, assessment and diagnosis
• Data handling in full accordance with data
  protection legislation

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Monitoring of screening programmes

• Regular monitoring of process outcome of
  organised screening by independent peer review
  and with quick reports to public and staff
• Adherence to ENCR (European Network of Cancer
  Registries) screening data base standards EU
  data protection laws
• Monitoring of programmes by national cancer
  registries at adequate intervals

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Training

• Personnel adequately trained at all levels to
  ensure delivery of high quality screening

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Compliance

• Priority for high compliance to organised
  screening based on fully informed consent
• Action taken to assure equal access to screening,
  accounting for special socio-economic groups

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Introduction of novel screening tests taking into
account international research results

• New screening tests only implemented after
  evaluation in RCTs
• Trials run on any of the following subjects (in
  addition to screening-specific parameters and
  mortality)
• Treatment procedures,
• Clinical outcomes,
• Side effects,
• Morbidity
• Quality of life
• Pooling of representative trials for assessment
  of level of evidence for new tests
• Final decision on routine implementation of new
  screening tests only after conclusive results in
  RCTs and based on cost-effectiveness in
  respective health care system
• Introduction of test modifications in routine
  health care only after evaluation of
  effectiveness, possibly using epidemiologically
  validated surrogate endpoints

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Population-based screening

• Population-based screening means that in each
  round of screening the persons in the eligible
  target population in the area served by a
  programme are individually identified and
  personally invited to attend screening.
• Population-based screening programmes generally
  require a high degree of organisation in order to
  assure that the invitational activities are
  performed reliably and effectively and are
  adequately coordinated with the subsequent steps
  in the screening process

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Ranking Of Cervical Cancer Incidence Relative To
Other Cancers In Europe (Incidence, All Ages)

• In 3 European countries Cervical cancer ranks as
  the 3rd most common cancer among women
• Romania,
• Moldova
• Macedonia

IARC, Globocan 2008
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Ranking Of Cervical Cancer Mortality Relative To
Other Cancers In Europe (Mortality , All Ages)
IARC, Globocan 2008
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Ranking Of Cervical Cancer Mortality Relative To
Other Cancers In Europe (Mortality , 15-44 Yrs )
In 71 of the European countries cervical cancer
ranks among the 3 most common cause of cancer
death in women 15-44 years
IARC, Globocan 2008
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Cancer Incidence And Mortality In Europe(All
Women)
7th
Annual age-standardized rates per 100,000 women
(all ages)
IARC, Globocan 2008
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Cancer Incidence And Mortality In Europe(Women,
15-44 yrs)
Annual age-specific rates per 100,000 women
(15-44 yrs)
IARC, Globocan 2008
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Estimated age-standardised rates (World) per
100,000
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Incidence Rates Of Cervical Cancer In Europe
Women gt15 years 325m ICC cases/yr
54,323 ICC deaths/yr 25,102  
Turkey 4.2
IARC, Globocan 2008
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Number of EU Member States by Type and Status of
CSP 2007
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30-60 year-old Women in the EU by Type and Status
of CSP 2007
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Screening

• Regular, systematic examination of predominantly
  asymptomatic individuals of average risk and of
  appropriate age using evidence-based screening
  tests followed by appropriate treatment has the
  potential to prevent many deaths due to these
  cancers and thereby significantly reduce the
  burden of disease in the population

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• Screening is performed on predominantly healthy
  persons
• Comprehensive quality assurance is also required
  to maintain an appropriate balance between
  benefit and harm in the large numbers of persons
  eligible to attend cancer screening programmes.
• Achieving and maintaining high quality at every
  step in the screening process requires an
  integrated, population-based approach to health
  service delivery.
• This approach is essential in order to make
  screening accessible to those in the population
  who may benefit and in order to adequately
  monitor, evaluate and continuously improve
  performance.

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The Recommendation of the Council of the European
Union

• Spells out fundamental principles of best
  practice in early detection of cancer and invites
  EU Member States to take common action to
  implement national cancer screening programmes
  with a population-based approach and with
  appropriate quality assurance at all levels,
  taking into account European quality assurance
  guidelines for cancer screening.

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Screening Tests

• Pap smear screening (cervical cytology) for
  cervical cancer precursors
• Starting not before the age of 20
• Not later than the age of 30 years
• The current second edition of the European
  Guidelines for Quality Assurance in Cervical
  Cancer Screening recommends 30-60 years or 30-65
  years as the minimum age group to target for
  cervical cancer screening.

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• The full age range targeted for cervical cancer
  screening varied considerably across the EU in
  2007
• The lowest age to begin screening was less than
  30 years in 21 Member States,
• The highest age targeted for screening was more
  than 60 or more years in 15 Member States.
• If women outside the 30-60-year-old age range are
  taken into account, approximately 146 million
  women were targeted by cervical cancer screening
  programmes which were running or being
  established in the EU in 2007.
• Approximately 32 million women in the EU attended
  screening programmes based on cervical cytology
  in 2007.

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Population for Screening

• in the EU in 2007
• 109 million women were in the age range 30-60
  years which corresponds to the minimum target age
  recommended in the recently published second
  edition of the European Guidelines for Quality
  Assurance in Cervical Cancer Screening.
• Five out of ten women within this age interval
  (51) were targeted for cervical cancer screening
  in 17 Member States which had adopted policies
  aiming at implementation of population-based
  screening programmes.

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• Two out of 10 women in this age group in the EU
  (22) were targeted for cervical cancer screening
  by the population-based programmes which were
  rolled out nationwide in seven Member States in
  2007.
• Five out of 10 women in this age group in the EU
  (47) were targeted by cervical cancer screening
  programmes in 12 Member States which have adopted
  non-population-based policies.
• Four Member States had dual programme type or
  status
• Two Member States were not running or
  establishing cervical screening programmes in
  2007.

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Policy consensus

• Denmark
• Estonia
• Finland
• France
• Hungary
• Ireland
• Italy
• Netherlands
• Poland
• Portugal
• Romania
• Slovenia
• Spain
• Sweden
• United Kingdom

• Cytology-based cervical cancer screening is also
  widely accepted as a public health policy in the
  EU.
• Population-based programmes are currently running
  or being established in 15 Member States

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Non-population-based screening programmes are
running in 12 Member States

• Austria,
• Belgium,
• Bulgaria,
• Czech Republic,
• France,
• Germany,
• Greece,
• Latvia,
• Lithuania,
• Luxembourg,
• Slovak Republic,
• Spain

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Number of persons affected by screening

• Significantly larger numbers of women are
  affected by the cervical cancer screening
  policies now being implemented in the EU than is
  the case with breast cancer screening, due to the
  extended target age range of cervical cancer
  screening programmes.
• The majority of the 30-60-year-old female
  population in the EU resides in Member States
  which have already established cervical cancer
  screening programmes nationwide.

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Programme implementation status in the EU

• Member states which have rolled out
  population-based programmes nationwide
• Denmark, Finland, Hungary, Netherlands,
  Slovenia, Sweden and the United Kingdom
  (Coverage is 22 of women aged 30-60 years )
• Member states which have established
  non-population-based programmes nationwide
• Austria, Belgium, Bulgaria, Czech Republic,
  France, Germany, Greece, Latvia, Lithuania,
  Luxembourg, and the Slovak Republic
• (Coverage is 41 of
  women aged 30-60 years)
• Nationwide population-based cervical screening
  programmes are currently being planned in
• Ireland and Portugal
  (Coverage is 3)
• Nationwide population-based cervical screening
  programmes are currently rolled out in
• Italy and Poland (Coverage is 20)
• A nationwide population-based cervical screening
  programme is currently piloted and planned in
• Romania (Coverage is 3)

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Variation between Member States

• The wider variation between the Member States in
  the way cervical cancer screening is implemented
  is also evident in programme policies on the
  duration of the screening interval and the age of
  women targeted for screening.

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In Turkey
9th most common female cancer Age-standardized
incidence 4.2/100.000 Age-standardized
mortality 1.6/100.000 IARC
3.9/100.000
GLOBOCAN 2008
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Cervical cancer in Turkey
New diagnosed 2008 1443
Death 556

• Incidence 4.2/100.000

• Parkin DM, Lancet Oncology Globocan 2008

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• TURKEY Male Female
  Both sexes
• Population 
  37.136.000 36.777.000 73.914.000
• Number of new cancer  55.800
  39.300 95.100  
• Age standardised rate (W) 182.3
  112.8 144.8  
• Number of cancer deaths  42.700
  24.500 67.200 
• Age-standardised rate (W) 141.1
  71.1 103.6 
• Risk of getting cancer before age 75 ()
• 19.8 11.7
  15.6
•  
• Risk of dying from cancer before age 75 ()
• 15.7 7.7
  11.5

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TURKEY Male Female
Both sexesPopulation  37.136.000
36.777.000 73.914.000
5 most frequent cancers
Male Female
Both sexesLung Breast
Lung Stomach Colorectum
Breast Bladder Stomach
Stomach Prostate Uterus
Colorectum Colorectum Ovary
Bladder
45
breast
other
colorectum
9 cervix
stomach
thyroid
Corpus uteri
Eusoph
ovary
lung
GLOBACAN 2008 TURKEY
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Cancer Incidence And Mortality In Turkey (All
Women)
Incidence
Mortality
9th
12th
IARC, Globocan 2008
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Current Cervical Cancer Screening Programme

• Screening Test Pap smear
• Target Age Group 30-65 years
• Screening Interval 5 years
• Non-population Based Screening

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Turkeys Capacity for Cervical Cancer Screening

• Pathologists 1100
• Cytopathologists None
• Target Population (30-65) 14 million
• Coverage Rate 20

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HPV-Based Screening Program proposed
algorithmFor settings where cytology exists
In EUROGIN 2008 roadmap on cervical cancer
prevention, Int J Cancer 2009 Adapted from
Cuzick J, Arbyn M, Sankaranarayanan R, Tsu V,
Ronco G, Mayrand MH, Dillner J, Meijer CJ.
Overview of human papillomavirus-based and other
novel options for cervical cancer screening in
developed and developing countries. Vaccine
200826(Suppl 10)K29K41.
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HPV-Based Primary Screening Program
Completion of 1st screening round for all women
eligible at baseline by Nov 2015
Phase III (Full coverage phase 3-4mill
capacity by Nov 2013
Launch of new program Nov 2010
Phase IV All KETEMs fully operational and
offering HPV screening services nationwide
Phase II (Extension Phase 2 mill capacity -
Nov 2012)
Phase I (Kick Off Phase - 1 mill capacity Nov
2011)
1 mill
3 mill
6 mill
9-10 mill
14 mill
Cumulative number women screened with HPV primary
screening test
51
New Turkish Cervical Cancer Control Strategy
HPV
PRECANCER
CANCER
15 y.
30 y
45 y
60 y
Screening will continue!