Download WHO`s cervical cancer screening programmes: managerial guidelines

WHO’s cervical cancer screening
programmes: managerial guidelines
by
Naila Baig Ansari
Research Fellow
Dept. of Community Health Sciences
The Aga Khan University
Karachi, Pakistan
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 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 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
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
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 women’s health issues
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
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.
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
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
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 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
invasive cervical cancer in Chile as a result of a single
screen at various ages
Age of single screen
% reduction in cum.
incidence
No. of tests in
population
(based on 1985 est pop.
of Chile)
30
35
37
40
11
15
17
20
88,000
81,000
81,000
70,000
45
26
57,000
50
60
26
21
45,000
34,000
Cost-effectiveness of two different strategies for cervical
cancer screening in Chile
Age
Frequency
Compliance
Reduction in
mortality
Reduction in
treatement costs
Cost per case
detected
Programme 1
Programme 2
30-55 years
3-yearly
30%
15%
30-50 years
10-yearly
90%
44%
US $0.13 million
US $0.25 million
US $2,522
US$556
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
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”
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
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.
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.
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.
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
Review Questions (Developed by the
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?