European Programme for Cervical Cancer Screening Dr Ahti Anttila Finnish Cancer Registry, Helsinki BALKAN MASTERCLASS IN C...
Burden of Colorectal, Breast and Cervical Cancer in the EU  in 2006   proportion of deaths from cancer by sex, except non-...
Cervical cancer in Europe <ul><li>54,300 new cases and 25,100 deaths estimated per year (Ferlay et al. 2010; Globocan 2008...
Fig. 1 .  Age-standardised rated of incidence of and mortality from cervical cancer  (/100,000 women-years) in the 27 memb...
EC Recommendation on Cancer Screening, 12/2003 <ul><li>Organised population-based screening  to maximise effect, minimise ...
EC Recommendation on Cancer Screening, 12/2003 <ul><li>Pap smear screening for cervical cancer </li></ul><ul><li>Mammograp...
Natural history of CIN and cervical cancer <ul><li>Length of pre-cancer phase on average 10-12 years </li></ul><ul><li>Pro...
Reduction in the cumulative rate of invasive Sq Cx Ca over the age range 35-64 years, with different frequencies of screen...
Sasieni & Cuzick, BMJ 2009
Examples of screening policy for cervical cancer in EU countries (Anttila et al. EJC 2009) No Yes 10-16 3 or 5 (20)25-(60)...
 
 
Death rates from cervical cancer in the Czech Republic and Finland
Estimated mortality trends from cervical cancers in some European countries  Arbyn et al. EJC 2009
Where can screening programme fail in its effectiveness? <ul><li>Women remain unscreened or underscreened – even though a ...
What about adverse effects of cervical cancer screening <ul><li>Failures in the diagnostic work, bad quality  </li></ul><u...
Status of cancer screening in the EU   (Karsa et al. 2008) <ul><li>27 Member States, 500 million population </li></ul><ul>...
Extension of  CERVICAL  Cancer Screening Programme Implementation in the EU  Estimated targeted proportion of 30-60-year-o...
Estimated number of Persons attending Breast, Cervical and CRC Screening Programmes in the EU by Target Cancer and  Progra...
BARRIERS IN PROVIDING/ATTENDING ORGANISED POPULATION-BASED SCREENING, SOCIETAL BARRIERS  Anttila et al., Tumori Issue, 201...
Adherence to recommendations and guidelines: Barriers among medical professionals and practitioners  <ul><li>” Culture” of...
EXAMPLES OF BARRIERS IN ATTENDANCE AMONG WOMEN <ul><li>Cluj, Romania: 10%-21% attended  Nicula et al, EJC 2009 ; the alloc...
Discussion: Challenges <ul><li>There have been extensive efforts to develop cervical cancer screening programmes in the EU...
Challenges in old MSs <ul><li>How to improve adherence to population-based models? </li></ul><ul><ul><li>Education, traini...
Challenges in new MSs <ul><li>Attendance and coverage yet at low level in most of these countries </li></ul><ul><ul><li>Ed...
FUTURE
CIN3+ cumulative incidence after screening visit (Dillner ym., BMJ 2008)
Detection rate ratio of CIN3+ in HPV group versus cytology group in 2 nd  screening round (M.Arbyn, EUROGIN 2010)
HPV screening and cervical cancer outcome <ul><li>50% decrease in mortality from cervical cancers compared with non-invite...
<ul><li>Considering the European setting, key problem for implementing population-based HPV-screening is that the programm...
Efficacy of HPV vaccination against CIN2+ irrespective of HPV type in lesion: an example using  Cervarix ®   <ul><li>Paavo...
Efficacy  on CIN3+/Referral/Local therapy /hrHPV   TVC naive cohort,  Cervarix ®   Paavonen J et al.  Lancet 2009; 374 (96...
Future Challenges  <ul><li>Organised population-based screening programmes  for cervical cancer are not yet in place throu...
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BALKAN MCO 2011 - A. Anttila - The European Commission programme for cervical cancer

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  • Local cervical therapy: surgical excision (LEEP, cone, knife and laser procedures) CIN3+ S 291 page 10485 CIN1+ S 292 page 10486 LCT S 294 page 10487
  • BALKAN MCO 2011 - A. Anttila - The European Commission programme for cervical cancer

    1. 1. European Programme for Cervical Cancer Screening Dr Ahti Anttila Finnish Cancer Registry, Helsinki BALKAN MASTERCLASS IN CLINICAL ONCOLOGY Dubrovnik 11-15 May, 2011 Finnish Cancer Registry Institute for Statistical and Epidemiological Cancer Research
    2. 2. Burden of Colorectal, Breast and Cervical Cancer in the EU in 2006 proportion of deaths from cancer by sex, except non-melanoma skin cancer* Women N = 536,700 Men N = 690,100 Breast 17% Cervix 3% Colon and rectum 13% Other 67% Colon and rectum 11% Other 89% * Estimates by IARC (2007) adapted from: Arbyn M, Autier P, Ferlay J (2007); Arbyn M, Raifu AO, Autier P, Ferlay J (2007); Boyle P, Ferlay J (2005); Ferlay J et al. (2007); Karsa et al. 2008
    3. 3. Cervical cancer in Europe <ul><li>54,300 new cases and 25,100 deaths estimated per year (Ferlay et al. 2010; Globocan 2008) </li></ul><ul><li>In the EU countries (n=27), the estimated numbers are 31,400 and 13,600 </li></ul>    Southern 3397 (14%) Northern 2094 (8%) Western 3794 (15%) Central/Eastern 15817 (63%)
    4. 4. Fig. 1 . Age-standardised rated of incidence of and mortality from cervical cancer (/100,000 women-years) in the 27 member states of the European Union, estimates for 2004 (direct standardisation using the World reference population). (derived from Arbyn et al. , Ann Oncol. 2007).
    5. 5. EC Recommendation on Cancer Screening, 12/2003 <ul><li>Organised population-based screening to maximise effect, minimise harms, quality assurance at all levels: </li></ul><ul><li>Evidence-based screening policy </li></ul><ul><li>Call-recall system to identify and invite target population, high acceptance and coverage of screening </li></ul><ul><li>Quality-assured diagnostics and treatment services </li></ul><ul><li>Centralized data systems with regular monitoring based on them </li></ul><ul><li>Screening database linked to cancer registry and mortality database; results on screening outcome available to stakeholders and populations at large </li></ul>
    6. 6. EC Recommendation on Cancer Screening, 12/2003 <ul><li>Pap smear screening for cervical cancer </li></ul><ul><li>Mammography screening for breast cancer </li></ul><ul><li>FOBT screening for colorectal cancer </li></ul><ul><li>European Guidelines for Quality Assurance in Cervical Cancer Screening, 2nd edition, issued in February 2008 </li></ul><ul><li>What is the current adherence to these recommendations and guidelines in the EU? </li></ul>
    7. 7. Natural history of CIN and cervical cancer <ul><li>Length of pre-cancer phase on average 10-12 years </li></ul><ul><li>Progression rates of CIN to invasive cancer (Oortmassen & Habbema, 1991) </li></ul><ul><ul><li>16% in lesions in age 18-34 years </li></ul></ul><ul><ul><li>60% in lesions in age 35-64 years </li></ul></ul><ul><li>Among 13 – 22 –years old girls and women up to 90 % of pre-cancer lesions regress naturally even in rather short-term follow-up (Moscicki et al.) </li></ul>
    8. 8. Reduction in the cumulative rate of invasive Sq Cx Ca over the age range 35-64 years, with different frequencies of screening (IARC 1986)     Assuming a negative screen occurring at age 35 years, and that a previous negative screen had been performed 4 64.1 10 years 7-8 83.6 5 years 12-15 90.8 3 years 31-44 93.5 1 year Number of tests % reduction in the cumulative rate Screening frequency
    9. 9. Sasieni & Cuzick, BMJ 2009
    10. 10. Examples of screening policy for cervical cancer in EU countries (Anttila et al. EJC 2009) No Yes 10-16 3 or 5 (20)25-(60)64 UK (England) Yes Yes 12 3 or 5 23-60 Sweden Yes Yes 15 3 20-64 Slovenia No Yes 7 5 30-60 Netherlands Yes No 11 3 30-60 Lithuania Yes No 50+ 1 20+ Germany Yes Yes 7 – 9 5 (25)30 - 60(65) Finland Yes No 45 1 25-69 Czech Republic Yes No 50+ 1 18+ Austria Non-popula tion based Population-based Smears per woman lifetime Screening interval (years) Target age
    11. 13. Death rates from cervical cancer in the Czech Republic and Finland
    12. 14. Estimated mortality trends from cervical cancers in some European countries Arbyn et al. EJC 2009
    13. 15. Where can screening programme fail in its effectiveness? <ul><li>Women remain unscreened or underscreened – even though a large proportion of the population may be screened regularly and frequently </li></ul><ul><li>Sampling or diagnostic error in screening test </li></ul><ul><li>Sampling or diagnostic error in triage or confirmation </li></ul><ul><li>Management error; e.g. drop-out prior to management or in the management follow-up, or inappropriate management procedure </li></ul><ul><li>Not optimal treatment of cancer </li></ul><ul><li>In many countries the whole of the screening chain has not been shown to work OK, the neceaary evaluation and audit has not been done. Therefore the current excess burden of cerical cancers is a more social or structural problem than simply a medical problem alone (related to diagnosis and management) </li></ul>
    14. 16. What about adverse effects of cervical cancer screening <ul><li>Failures in the diagnostic work, bad quality </li></ul><ul><ul><li>False negatives: failure to treat in precancer phase </li></ul></ul><ul><ul><li>False positives or negatives: psycho-social morbidity, labeling </li></ul></ul><ul><li>Tests and treatments in too young women or with too short intervals </li></ul><ul><ul><li>Failures in reproductive functioning: pre-term delivery, low birth weight, are there other failures? </li></ul></ul><ul><ul><li>Complications, consequences if too aggressive treatment </li></ul></ul><ul><li>Information and communication with women failed </li></ul><ul><li>Excess cost due to overuse of services </li></ul>   
    15. 17. Status of cancer screening in the EU (Karsa et al. 2008) <ul><li>27 Member States, 500 million population </li></ul><ul><ul><li>109 million women 30-60 yrs (Cx) </li></ul></ul><ul><ul><li>59 million women 50-69 yrs (Bc) </li></ul></ul><ul><ul><li>140 million men and women 50-74 yrs (CR) </li></ul></ul><ul><li>Extension of cancer screening programmmes: </li></ul>30% 27% 43% 0% Colon & rectum 4% 6% 50% 41% Breast 3% 47% 29% 22% Cervix No program or no data Non-population-based only Population-based: planning, piloting, rollout Population-based complete Cancer type
    16. 18. Extension of CERVICAL Cancer Screening Programme Implementation in the EU Estimated targeted proportion of 30-60-year-old women in the EU by programme type and implementation status in 2007 Karsa et al., 2008 Population-based 22% 29% Rollout complete Rollout ongoing 20% Nationwide Planning / Piloting 7% Nationwide Regional 2% Non population-based nationwide 47% 41 nationwide 7 regional <1% no prog. 2% Excluded
    17. 19. Estimated number of Persons attending Breast, Cervical and CRC Screening Programmes in the EU by Target Cancer and Programme Type in 2007 Estimates corrected for programmes in rollout phase and for missing data in Austria, Latvia, Greece, and Slovak Republic (all programmes) and in Denmark, France and Spain for cervical screening; and in Bulgaria for CRC screening. KARSA ET AL. 2008
    18. 20. BARRIERS IN PROVIDING/ATTENDING ORGANISED POPULATION-BASED SCREENING, SOCIETAL BARRIERS Anttila et al., Tumori Issue, 2010 <ul><li>Policy and organisation not defined (e.g. resources not available; or use of resources to other purposes) </li></ul><ul><li>Invitations not in place </li></ul><ul><li>Use of non-validated tests and methods </li></ul><ul><li>Fail-safe is missing (e.g. a woman not systematically followed after a referral, or after a negative test) </li></ul><ul><li>Registration, monitoring & evaluation is missing; no distinct information available about the quality and outcome </li></ul>
    19. 21. Adherence to recommendations and guidelines: Barriers among medical professionals and practitioners <ul><li>” Culture” of opportunistic services; e.g. role of gynaecologists often in private ambulatories, does not include population-based action models Arbyn et al. 2009; Viberga et al. 2010 </li></ul><ul><li>Cytologists etc key professionals may need extensive re-training after using non-standard methods over decades Viberga et al. 2010 or if properly trained staff is lacking Nicula et al. 2009 </li></ul><ul><li>Insufficient communication and interaction with decision-making Todorova et al. 2006; Nicula et al. 2009; Valerianova et al. 2010 </li></ul><ul><ul><li>Insufficient knowledge regarding effectiveness of screening </li></ul></ul><ul><ul><li>Insufficient organisational models & financing </li></ul></ul>
    20. 22. EXAMPLES OF BARRIERS IN ATTENDANCE AMONG WOMEN <ul><li>Cluj, Romania: 10%-21% attended Nicula et al, EJC 2009 ; the allocated screening resources did not enable to screen more? </li></ul><ul><ul><li>Implications on how to inform the population? </li></ul></ul><ul><li>Estonia: Attendance about 15% after invitation; however, about 50% had been reimbursed of at least one smear test outside the programme within 3 years Veerus et al. 2010 </li></ul><ul><li>Poland: appr. 10%-30% attendance Chil et al. 2009 wide use of services outside the programme, no information about it </li></ul><ul><li>Well-to-do settings: coverage/attendance 70-90%, but with large overuse of services and still in many settings a remarkable fraction of under-screened Anttila et al. 2009; Arbyn et al. 2009 </li></ul>
    21. 23. Discussion: Challenges <ul><li>There have been extensive efforts to develop cervical cancer screening programmes in the EU during the late 2000s </li></ul><ul><ul><li>Planning, piloting or rollout of new programmes </li></ul></ul><ul><ul><li>Increase in the number of national or regional screening registers </li></ul></ul><ul><ul><li>Increase of other computerised datasets in health-care </li></ul></ul><ul><li>In general, the Council Recommendation is not fullfilled as about half of the population is not yet covered by the quality-assured population-based screening programmes </li></ul>
    22. 24. Challenges in old MSs <ul><li>How to improve adherence to population-based models? </li></ul><ul><ul><li>Education, training, attitudes among medical groups? </li></ul></ul><ul><ul><li>Building up invitational & information systems, to reduce numbers of non-screened and under-screened which may still be substantial </li></ul></ul><ul><ul><li>Legal frameworks enabling organised screening </li></ul></ul><ul><li>Reducing overuse of services and adverse aspects of screening </li></ul><ul><ul><li>Not to start at too early age </li></ul></ul><ul><ul><li>To reduce lifetime tests provided for healthy women </li></ul></ul><ul><ul><li>Include all tests and treatments in the evaluation systems </li></ul></ul><ul><li>Be prepared to introduce new methods in organised programmes </li></ul>
    23. 25. Challenges in new MSs <ul><li>Attendance and coverage yet at low level in most of these countries </li></ul><ul><ul><li>Education, campaigning among medical groups and women </li></ul></ul><ul><li>Often adequate capacity of screening tests exists, but onl y little or no decrease in the historical disease burden. No validation based on linkage studies to show that screening is effective </li></ul><ul><li>There are few countries without the necessary capacity of the quality-assured service </li></ul><ul><li>How to increase research and piloting with new screening technologies in these countries? </li></ul><ul><li>Invest adequate resources in screening evaluation and management, instead of planning financially demanding programmes </li></ul>
    24. 26. FUTURE
    25. 27. CIN3+ cumulative incidence after screening visit (Dillner ym., BMJ 2008)
    26. 28. Detection rate ratio of CIN3+ in HPV group versus cytology group in 2 nd screening round (M.Arbyn, EUROGIN 2010)
    27. 29. HPV screening and cervical cancer outcome <ul><li>50% decrease in mortality from cervical cancers compared with non-invited controls in single-round screening (Sankaranarayanan et al. 2009) </li></ul><ul><li>No cervical cancer cases at round 2 among women who had HPV-based screening at round 1 whereas nine cases were observed among women who had cytology-based screening at round 1 (p=0.004) (Ronco 2010) </li></ul><ul><li>Data still scarce, more follow-up studies on-going </li></ul>
    28. 30. <ul><li>Considering the European setting, key problem for implementing population-based HPV-screening is that the programme aspects are missing in many countries; they need to be built in order to achieve readiness to maximise impact and control for potential adverse aspects </li></ul><ul><li>Careful planning and piloting for primary HPV screening encouraged </li></ul>Take home on HPV screening
    29. 31. Efficacy of HPV vaccination against CIN2+ irrespective of HPV type in lesion: an example using Cervarix ® <ul><li>Paavonen J et al. Lancet 2009; 374 (9686): 301 - 314. </li></ul><ul><li>2. http://www.who.int/hpvcentre/statistics. Accessed 1 May, 2009 . </li></ul>Estimated worldwide prevalence of HPV 16/18 in high grade lesions (CIN 2/3) is 52% 2 54.7–80.9 70.2 1 TVC na ï ve CIN2+ irrespective of HPV type in lesion, DNA negative for all high-risk HPV types at baseline 16.4–42.1 30.4 1 TVC-1 CIN2+ irrespective of HPV type in lesion, irrespective of baseline HPV DNA status 95% CI VE % Cohort Endpoint Phase III study
    30. 32. Efficacy on CIN3+/Referral/Local therapy /hrHPV TVC naive cohort, Cervarix ® Paavonen J et al. Lancet 2009; 374 (9686): 301 - 314 <0.0001 36 19 28 803 585 Any oncogenic HPV, 12 month persistent infection <0.0001 98 55 87 23 3 CIN3+ irrespective HPV DNA P-value UL LL VE (%) Control HPV Final Analysis, Phase III study <0.0001 36 15 26 476 354 Colposcopy referrals <0.0001 81 50 69 83 26 Number of cervical excision procedures
    31. 33. Future Challenges <ul><li>Organised population-based screening programmes for cervical cancer are not yet in place throughout Europe, planning and piloting them in a priority </li></ul><ul><li>Consider introducing primary HPV screening but only in organised population-based programmes </li></ul><ul><li>No follow-up data on impact of HPV vaccination programme on cervical and other HPV related cancers exist, yet it is important to consider the potential synergies of the primary and secondary prevention strategies (ECDC 2008) </li></ul>
    32. 34. Thank you for your attention!

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