DEVELOPING A COORDINATED CERVICAL CANCER SCREENING PROGRAM IN LATIN AMERICA

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DEVELOPING A COORDINATED CERVICAL CANCER
SCREENING PROGRAM IN LATIN AMERICA

• CARLOS SANTOS, MD

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CERVICAL CANCER IN LATIN AMERICA Population

• 21 COUNTRIES
• YEAR POPULATION
  PERCENT GLOBAL
• (Millions) POPULATION
• 1990 445 8
• 2000 600 9
• 2020 700 13
• PANAMA lt 3 Millions
• BRAZIL gt 190 Millions
• 35 POOR
• 19 EXTREMELY POOR

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CERVICAL CANCER IN LATIN AMERICAMAGNITUDE OF THE
PROBLEM
Developed 20
Latin America 15
Worwide 500, 000 cases / year
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CERVICAL CANCER IN LATIN AMERICAMAGNITUDE OF THE
PROBLEM

• DATA RELIABILITY
• Scarcity of population based registries
• Sustainability of registries
• Underdiagnosis
• Underregistry
• Wrong population estimation

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The Cancer Registries
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CERVICAL CANCER IN LATIN AMERICAAmericas
Incidence

• ASR
• CARRIBEAN 32.6
• CENTRAL 30.6
• SOUTH 28.6
• NORTH 7.7

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The Most Frequent Female Cancer Sites 1994-1997
Incidence Mortality
Female breast
Cervix uteri
Stomach
Other skin
Lung
Ovary
Non-Hodg.lymp.
PSU
Colon
Thyroid
Brain
Leukaemia
Gallbladder
n 11 071
n 21 051
Registro de Cáncer Lima Metropolitana
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CERVICAL CANCER IN LATIN AMERICA Female Cancer
Incidence
Age. - standarized rate 100,000
Registro de Cáncer de Trujillo 1991 - 95
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CERVICAL CANCER IN LATIN AMERICA Worldwide
Highest Incidence Rates
Haiti
Pernambuco
Harare
Belén
Trujillo
Asunción
Rate / 100,000
CIFC, IARC, 1982 - 87, 92, 97 Globocan 2002
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CERVICAL CANCER IN LATIN AMERICAAmericas
Mortality

• ASR
• CARRIBEAN 16
• CENTRAL 15
• SOUTH 12.9
• NORTH 2.3

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CERVICAL CANCER IN LATIN AMERICA
COMPARATIVE MORTALITY 2.8 14 14 23.8 23.8
55.6 Argentina Colombia Bolivia Brazil Ecu
ador Paraguay Chile México Perú Uruguay Nica
ragua Haiti Costa Rica Venezuela Panamá Hond
uras Cuba El Salvador Puerto
Rico Guatemala Dom. Rep.
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BOLIVIA

• Extensión territorial 1.098.581
  Km2.
• Population
  8.274.325
• Índice de crecimiento
  2.74
• Índice de alfabetización
  87.2

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BOLIVIA

• High incidence (58/100,000) and mortality rates

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GOALS2004 - 2008

• INCIDENCE 15
• MORTALITY 30
• COVERAGE 30

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AREA DE REFERENCIA
SANTA CRUZ

• POBLACION TOTAL 2,388.799
• POBLACION DE RIESGO
• Mujeres de 20 a 64 años
• 21 del total 501.648 mujeres
• POBLACION ASIGNADA
• 55 de la población de riesgo
• 276.000 mujeres a controlar en 3 años
• 92.000 mujeres por año Laboratorio con
  capacidad para 100.000 Pap.por año
• ( 45 de la población de riesgo es atendida por
  seguros, ONG y medicina privada) .

SANTA CRUZ DE LA SIERRA
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SANTA CRUZ

• Population coverage 9.28
• Abnormal cytology 4.33
• Lack of compliance 30.00

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Country Major elements of the strategy
Cuba Cervical cancer programme Ecuador Cervical
cancer programme Peru Cervical cancer
programme Venezuela Cervical cancer
plan Mexico Cervical cancer programme Brazil Com
prehensive cancer control strategy Costa
Rica National cervical cancer programme Colombia S
trategies for information systems, education,
intersectoral coordination, research and
legislation Chile Prevention cervical cancer
programme, curable tumours and palliative care.
National Cancer Control Programmes policies and
managerial guidelines 2nd ed. WHO. 2202
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UICC Central America Cervical Cancer Project

• Weaknesses
• Coverage
• Target population (age)
• First time screened
• Lack of quality control
• Aftercare

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CERVICAL CANCER

• SCREENING
• Steps of a Classic Program
• Sampling
  Report
• Fixation
  Sending report back
• Transport
  Colposcopy
• Processing
  Results
• Reading
  Treatment

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ELEMENTS OF GRAND STRATEGY TO CONTROL CANCER

• Approaches to prevention and treatment will also
  need to be molded to fit different socioeconomic
  and cultural circumstances

INCTR NETWORK, Vol 4 nº 1, Summer 2003
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CERVICAL CANCER IN LATIN AMERICACervical
Cancer Control

• ALTERNATIVE APPROACH
• Two concepts
• Diagnosis VIAA - VIAAM
• Treatment See and Treat

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ACCURACY OF SCREENING TESTS
How accurate is cytology in developing countries
in detecting CIN 2 and 3 lesions?
Denny et al., Cancer 2000 89 826-33 Denny et
al., Cancer 2002 941699-707 Lancet 1999 353
869-73Cronje et al., Am J Obstet Gynecol 2003
188 395-400 Salmeron et al., Cancer Causes
Control 2003 14 505-12 Sankaranarayanan et
al., J Med Screening 2004 110 907-13.
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ACCURACY OF VIA (for CIN 2 Diseases)
Denny et al., Cancer 2000 89 826-33 Denny et
al., Cancer 2002 941699-707 Belinson et al.,
Obstet Gynecol 200198 441-44 Lancet 1999 353
869-73 Cronje et al., Am J Obstet Gynecol 2003
188 395-400 Sankaranarayanan et al., Int J
Cancer 2004110907-13.
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CERVICAL CANCER IN LATIN AMERICA
One Session CIN Management in Developing
Countries
Adequacy of Day Management
Undermanaged
Adequately Managed
Overmanaged
N 639
Santos et al Gyn Onc 61 11(April 1996)
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TATI
Screening and Immediately Treatment for Cervix
Displasia
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DEPTH OF NECROSIS IN CO2 CRYOTHERAPY OF THE CERVIX
5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0
Required Depth Of Necrosis
Depth of necrosis (mm)
3 minute 5 minute
0 2 4
6 8 10
12 14 16 18

Individual
Santos et al
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I.N.E.N
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• ESCUELA LATINOAMERICANA DE CÁNCER DE CÉRVIX
• INEN - IARC
• INCTR
• Regional Training Center

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• Where screening quality and coverage of the
  population are felt to be high, we must organize
  or reinforce the establishment of the classic
  cytology-based system.

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CERVICAL CANCER IN LATIN AMERICA

• Until a better tool is established
  (vaccine??) combination of SV with VIAA and CRYO
  OR LEEP may offer the best model.

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DECENTRALIZATION
THIRD STEP
INSTITUTES
ONCOLOGIC UNITS
ONCOLOGICS U. RADIOTHERAPY
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Mapping
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The emphasis should be on adequate coverage of
target women with screening, treatment and
follow-up, irrespective of whatever test is used.
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CERVICAL CANCER IN LATIN AMERICA Cervical Cancer
Control LEVELS OF ATTENTION
Colp RT Rad.Sur. Chemo
Onc Rther
VIAAM Colposcopy LEEP CONE Histerectomy
Gynecologist
Midwives Leaders
VIAA - CRYO EDUCATION
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