Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CPHA HPV Vaccination into Cervical Cancer Screening: NL lessons learned Cathy O’Keefe, Cathy Popadiuk, Joanne Rose May 27, 2014 Disclosure • Cathy Popadiuk • Speaker and Advisory Board Contributions to Merck and GSK for HPV vaccination and cervical screening. • Cervical Cancer Lead for the HPV- Cervix Cancer Risk Management Model (CPAC) Objectives • Describe the elements for implementation of an organized prevention and screening programme applicable to all systems. • Identify barriers to achieving a successful and seamless prevention and screening programme. • List strategies to facilitate creation of common goals to achieve streamlining of seemingly fragmented processes and goals. Newfoundland and Labrador Organized Cervical Cancer Screening Dr Cathy Popadiuk MD, FRCS History of Pap Smear Screening in Canada • 1949: BC - Boyes and Fidler started centralized system • 1950: Ontario started. Lab organized 1957 • 1962: 6.3% Canadians screened • 1967: 26% Canadians screened BUT only 13% of women in Newfoundland screened! National History • 1976: Walton National Task Force concluded need organized screening program • 1982: Task Force reconvened. Same recommendations • 1989: National Workshop on Screening for Cancer of the Cervix. 27 recommendations • 1995: Interchange 95 National Workshop to assess if recommendations still valid • 2004 Pan Canadian Forum on Cervical Cancer Screening • 2006 Federal Government Funding for HPV Vaccination • 2013 Canadian Task Force Preventive Health Guidelines Components of Organized Screening Program • • • • Information Systems Quality Control and Improvement RECRUITMENT Education of service providers and attendees Failure Analysis • • • • • • • • Failure to attend screening Failure to take a satisfactory smear Failure to fix and stain the smear Failure to identify abnormal area on smear Failure to classify abnormality on smear Failure to recommend investigation and Rx Failure to attend for investigation and Rx Inadequate treatment or follow-up NL: Cutting Edge Cervical Cancer Prevention and Screening Coordination and evaluation of new technologies and products challenging to all health care providers Where are the Canadian Provinces and Territories Today with Cervical Cancer Prevention? Provincial Screening Programmes HPV Immunization Programmes in Canada What is happening in the rest of the World with Cervical Cancer Screening and Prevention? www.thelancet.com Published online November 3, 2013 http://dx.doi.org/10.1016/S01406736(13)62218-7 Prof Emeritus Public Health University of Toronto • “This is the second study to report no long term benefit of HPV screening over cytology (the earlier paper was on a trial in Finland). Their conclusion is that the earlier trials showing sensitivity benefit of HPV screening over cytology was an early diagnosis phenomenon, not over diagnosis from HPV testing. • But this also means that the delay associated with the lesser sensitivity of cytology had no long term disadvantage. • So that as in some respects there is the likelihood of an adverse quality of life for longer duration living with the knowledge of an abnormal screening test, choosing between the two for policy purposes will depend on relative costs, not effectiveness.” Lancet 2011; 377: 2085–92. Discussion & Questions Program structure of the Newfoundland and Labrador Cervical Screening Initiatives Program Joanne Rose Program Elements: √ Target group & frequency for screening √ Informed target group √ Means to invite women for screening and re-screening √ Competent facilities for collection, processing & reporting pap tests √ Means to ensure women with abnormal test result attend for care Program Elements: continued.. √ Effective and efficient treatment of abnormalities √ Means of monitoring coverage of women at risk and other relevant process measures √ Means of monitoring disease in population and relating to screening history X Population database HCP involvement Screening Modality • Screening target women ages 20-69 years • Liquid Based Cytology (LBC) • Reflex testing for HPV for women over 30 √ years of age with a diagnosis of a borderline abnormality (ASCUS) • Available through some 700+ health care providers (HCPs) throughout the province Participation of target Contact with Women Limitation: Privacy barrier Invitation system via the HCP’s generated annually to all recruited HCP Follow up for abnormal cytology via HCP x 2, then correspondence directly to women Competent facilities: • Laboratory quality assurance (OLA & Bethesda) • Programmatic indicators for turn around time, diagnostic statements, time to colposcopy, biopsy taken and cytology histology correlation Abnormal Follow up: Effective Treatment Limitation: geography, 4 RHAs, no established communication linkage… •Provincial Colposcopy Committee Structure •Comprehensive Environmental Scan with patient flow, service provision, wait times and best practice review. Wait time to Colposcopy 2010 Monitoring: Women ages 20 to 69 years: • Participation rates 2009-2011: 74% • Retention Rates 2009-2011: 81% • Age standardized Incidence Rate: 16% • Disease diagnosed at stage 1: 58% Population Database Limitation: Privacy legislation Allow for linkage for individual women requiring follow up of abnormal cytology. Currently a provincial registry committee addressing the most expedient way to work with the legislation. Provincial Cervical Cytology Registry PCCR Joanne Rose (on behalf of Susan Ryan for the NL Cervical Cytology Registry) Registry: Provincial Cervical Cytology Registry (PCCR) • Centralized database of all pap reports, HPV test results, and high grade positive biopsy results, plus related colposcopy reports Limitations: Colposcopy reports are submitted on paper Biopsy records are only for high grade dx Solution? • Electronic Health Record for colposcopy with a built interface for transfer to PCCR • Pathology extract for all gynecological surgical reports including biopsies, endocervical curretage and hysterectomies. How to make this work? Next steps for PCCR • Integration of HPV vaccine data Limitation: no population database, solution to incorporate new patient information first and then new vaccine records thereby creating our new population cohort Limitation: no field for record, solution build a new field in PCCR with patient identifiers What will this do? • Allow monitoring of the indicators such as participation and retention • Allow monitoring of disease in vaccinated and un-vaccinated population • Allow for research opportunities and surveillance of HPV genotyping Discussion & Questions HPV VACCINATION AND THE INTEGRATION INTO THE CERVICAL SCREENING PARADIGM: NACI recommendations • NACI initial statement February 2007 Prevent cervical cancers caused by HPV infection • NACI statement updated in 2012 HPV4 (Gardasil®) is recommended in males between 9 and 26 years of age for the prevention of anal intraepithelial neoplasia (AIN) grades 1, 2, and 3, anal cancer, and anogenital warts (NACI Recommendation Grade A). NACI has determined that there is good (Grade A) evidence to recommend the use of Gardasil® in males between 9 to 26 years of age. To date PEI and Alberta have announced programs for males Getting started 21 March 2007 • Canadian Cancer Society Applauds Funding for HPV Vaccine Announced in Federal Budget • TORONTO - The Canadian Cancer Society applauds the federal budget announcement of $300 million to help implement the HPV vaccine across Canada. The vaccine will help protect young women and girls from cervical cancer. Getting the best coverage NL factors for choosing a cohort • Age of initiation of sexual activity • Impact of school size and class attendance • Duration of protection • Ongoing surveillance and connection with cancer registry Regional Participation • The key component of making this work is collaboration with Regional Health Authorities in planning • Some of the questions- What works best: – Grade - Age – Timing - Involving teachers – Materials for parents and teachers – PH Nurse training – Should we involve media NL The process 2007 • Fall 2006 Communicable Disease Nurses and Regional Medical Officers of Health were provided scientific information on HPV infection and vaccine • Once NACI announced – managers had heard that implementation was most likely going to be fall 2008, but nevertheless did pass this info on to lower level managers who had been asked to work out the logistics... – so when the announcement was made, there was little difficulty mobilizing because much of the work was done HPV NL Implementation August September 2007 • Policy developed Materials: Education for health professionals Informed consent Fact sheet to facilitate consent Post immunization fact sheet Information package for teachers • Flexibility in regions for operationalization Consent Implementation • PH Nurses in-service on science and responding to parental concerns • Materials printed • Policies revised and distributed • Work with Department of Education to develop an information package for school boards and teachers on HPV program • Regions provided with vaccine, materials for education Adding another Cohort • As many of the PT came on board and costs reduced the key was to ensure equitable use of all the NIS trust funding • Add cohort grade 9 for 2 years – Already completing a consent for Tdap – Not covered in 08-09 by the grade 6 program – 2 years Result: 90% of females born 1994 and after have been immunized 2007-2010 100 95 90 85 80 75 2007 2008 2009 2010 Goal Reaching the goal Why this works • All post natal referrals in this region are sent to PH nurses for follow-up. • PH nurses use this opportunity to provide an appointment for child health clinics. The first vaccinations are at 8 weeks, two weeks later than the doctor’s the 6 week appointment. • Also since the parent is called and an appointment is provided for immunization, the parent is made to feel it is important to have vaccines. • All school based immunization programs are completed by PH nurses allowing physicians to work toward their scope of practice. Why this works • Single service provision of Childhood immunization Program • • • • Only one group responsible for provision of this service Public Health Nurses cover all communities Clear lines of communication for issues that arise They are directed and follow provincial policies and procedures. • Have our immunization manuals to follow so there are clear consistent messages • Strong support from provincial office: prompt response to concerns that arise Why this works • Issues and concerns were dealt with promptly. PHNs fell their work is valued and they take ownership of the immunization program. • Vaccine products are changing continuously • PHNs are immediately educated about any program changes or changes to vaccine product • Written materials such as tear off sheets are provided promptly as well as product information • Semi-monthly Public Health memo send from the CDCN keeps the PH nurses abreast of changes Opportunities • Linking immunization records to the cancer registry • HPV monitoring and Surveillance Committee • Reviewing policy related to immunizing males Discussion & Questions Tools to Help Put the Information Together At the Policy and Education Level Evaluating Screening and (HPV) Vaccination Strategies in Canada using the Cancer Risk Management HPV Microsimulation Model (CRM-HPVMM) Data Sources Data Type Source Mortality, Birth, Population projections Vital Statistics (1950-2005), Census (2006, 2011) Incidence, Staging Canadian Cancer Registry (2004-2007) Smoking rates, Population health utilities Canadian Community Health Survey (2000-2007), National Population Health Survey (1994-2004) Time use data General Social Survey (2005) Earnings, Transfers, and Taxes Census 2006, SPSD/M v16.1 (2005) Total health care expenditures Canadian Institute for Health Information (2006) Health care costs: diagnosis, treatment, follow-up, palliative and terminal care Ontario Case Costing Initiative (2007-2008), Provincial formulary (2009), Provincial Ministries of Health (2009) Current treatment practice Expert Opinion Screening parameters, Lung cancer risk equation, Radon mitigation options, Radon exposure, sexual network, HPV virus transmission Literature Cancer Survival Chart review (1991-92), Literature (1981, 1990-2000, 2005) Cancer Risk Management Model (CRMM) overview Target populations Participation rates Various modalities New Treatment Δ Cost Δ Survival Δ Health utility Incidence Treatment Progression Year Cancer Sex Screening Cancer incidence Cancer deaths Resource needs Direct Health Care costs Cost per life-year gained Life expectancy Health-adjusted LE Economic impacts Province Outcomes Lifestyle Environmental Socio-Economic Status Presence of virus Age Risk Factors http://goanimate.com/videos/0ObXRlXaYuMQ?utm_source=linkshare 70 Epidemiological Evaluation of Screening Policies Incidence of Cervical Cancer Effect of screening interval 2,500 2,000 1,500 1,000 500 Screening every 2 years Screening every 3 years Screening every 2.5 years Screening every 5 years 0 2012 * non-age-standardized data 2017 2022 2027 2032 2037 2042 2047 2052 Mortality Effect of screening interval on cervical cancer deaths 1,000 900 800 700 600 500 400 300 200 100 Screening every 2 years Screening every 3 years 0 2012 * non-age-standardized data 2017 2022 2027 Screening every 2.5 years Screening every 5 years 2032 2037 2042 2047 2052 Incidence Effect of age at starting screening on new cervical cancer cases 2,500 2,000 1,500 1,000 500 Age 18-69 Age 21-69 Age 25-69 Age 30-69 0 2012 * non-age-standardized data 2017 2022 2027 2032 2037 2042 2047 2052 Mortality Effect of age at starting screening on cervical cancer deaths 900 800 700 600 No incremental benefit to screening 18-20 year-olds when compared to screening 21-69 500 400 300 200 100 Age 18-69 Age 21-69 Age 25-69 Age 30-69 0 2012 2017 * non-age-standardized data 2022 2027 2032 2037 2042 2047 2052 Incidence Effect of screening participation on new cases of cervical cancer 4,500 Interval: triennial Age: 21-69 4,000 3,500 50% reduction 3,000 2,500 2,000 1,500 1,000 500 No screening 0 2012 2017 2022 70% screening 2027 50% screening 2032 2037 100% screening 2042 2047 2052 68% reduction (from no vaccination) at year 2052 Additional 8% reduction (from no vaccination) at year 2052 HPVMM 1.6 Incidence Impact of screening & vaccination on new cases of cervical cancer 2,500 42% difference 2,000 1,500 1,000 500 70% screening, 0% vaccination 70% screening, 75% vaccination 0 2012 * non-age-standardized data 2017 2022 2027 2032 2037 2042 2047 2052 New cases of cervical cancer • 40% reduction in incidence cases at year 2052 • 17% reduction in cumulative incidence cases (20122052) Model Summary • Less frequent screening is more cost-effective • Including vaccination programs with screening is more cost-effective than screening alone • There may be a threshold vaccination rate that achieves an adequate reduction in cervical cancer incidence (herd immunity) Final Objective • The objective for the panel is to offer tangible solutions and action plans for participants to bring back to their respective regions.. In Summary PREPAREDNESS MEETS OPPORTUNITY = LUCK •Regardless of one’s particular political climate or circumstances, perseverance and hard work will eventually come together. •Take on realistic short term goals in response to abrupt perturbation •Don’t lose focus for the end result!!!! The End Thank you Discussion & Questions