WHO’s cervical cancer screening WHO’s cervical cancer screening programmes: managerial guidelinesprogrammes: managerial guidelines

by

Naila Baig Ansari

Research Fellow

Dept. of Community Health Sciences

The Aga Khan University

Karachi, Pakistan

Who am I?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

Learning ObjectivesLearning 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

Performance ObjectivesPerformance 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

IntroductionIntroduction

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

IntroductionIntroduction 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 women’s health issues

Managerial factors to consider when Managerial factors to consider when setting up a screening programme 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

Natural HistoryNatural 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.

Risk Factors identifiedRisk 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

Implementation and evaluation of Implementation and evaluation of cervical screeningcervical 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

Which health service sector?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

Frequency of screeningFrequency 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

Estimated reduction in the cumulative incidence of Estimated reduction in the cumulative incidence of invasive cervical cancer in Chile as a result of a single invasive cervical cancer in Chile as a result of a single

screen at various agesscreen at various ages

Age of single screen% reduction in cum.

incidence

No. of tests in population

(based on 1985 est pop. of Chile)

30 11 88,000

35 15 81,000

37 17 81,000

40 20 70,000

45 26 57,000

50 26 45,000

60 21 34,000

Cost-effectiveness of two different strategies for Cost-effectiveness of two different strategies for cervical cancer screening in Chilecervical cancer screening in Chile

Programme 1 Programme 2

Age 30-55 years 30-50 years

Frequency 3-yearly 10-yearly

Compliance 30% 90%

Reduction in mortality

15% 44%

Reduction in treatement costs

US $0.13 million US $0.25 million

Cost per case detected

US $2,522 US$556

Screening in Primary Health CareScreening 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

What is “downstaging” for cervical What is “downstaging” for cervical cancerscancers

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”

Possible approaches to “downstaging” for Possible approaches to “downstaging” for cervical cancercervical 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

Example of process and impact measures to Example of process and impact measures to monitor and evaluate downstaging: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.

Example of outcome measures to monitor Example of outcome measures to monitor and evaluate downstaging: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.

Cancer Control ProgramCancer 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.

Online sources of interestOnline 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

Review Questions (Developed by the Review Questions (Developed by the Supercourse team)Supercourse team)

What is the common cause of most cervical cancers diagnosed around the world?

Describe the importance of cervical cancer screening.Why do developing countries have higher burden of

cervical cancer mortality than developed countries?