ACCP Evidence base: Implications for policy and practice

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ACCP Evidence base Implications for policy and
practice
R. Sankaranarayanan MD Head, Screening
Group World Health Organization
(WHO) International Agency for Research on Cancer
(IARC) Lyon, France http//screening.iarc.fr
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ACCP Evidence Base

• Test characteristics
• Efficacy of treatment of CIN
• Effectiveness of reducing disease burden
• Cost effectiveness issues
• Acceptability of participation determinants

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ALTERNATIVE PROGRAMMATIC APPROACHES

• Reduced frequency of screening one or twice a
  life time
• Reducing the number of visits and improving
  adherence to treatment
• screen and treat (1 or 2 visits)
• screen, see (colposcopy), and treat (1 to 2
  visits) (with a posteriori histological
  confirmation)

RTCOG/ JHPIEGO Lancet, 2003 361 814-20
Sankaranarayanan et al., Int J Cancer, 2004 109
461-7 Denny et al., 2005 JAMA 294 2173-81
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Accuracy of screening tests in developing
countries range in sensitivity and specificity
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RESULTS OF TREATMENT OF CIN
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SAFETY, ACCEPTABILITY, AND FEASIBILITY OF A
SINGLE-VISIT APPROACH TO CERVICAL CANCER
PREVENTION IN RURAL THAILAND
Acceptability of Cryotherapy Treatment
Women
Lancet 2003 361814-820
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RANDOMISED CONTROLLED TRIAL OF SCREEN AND TREAT
APPROACH FOR CERVICAL CANCER PREVENTION IN SOUTH
AFRICA
Denny et al., JAMA 2005 294 2173-81
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Cluster Randomised Controlled Trial of VIA
Screening, Dindigul District, India
Christian Fellowship Community Health Centre
(CFCHC), Ambillikai, India PSG Institute of
Medical Sciences and Research (PSGIMSR),
Coimbatore, India Cancer Institute (WIA),
Chennai, India World Health Organization-Internati
onal Agency for Research Cancer (WHO-IARC), Lyon,
France
Supported by the Bill Melinda Gates Foundation
through the ACCP
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Study design
113 Village clusters 79 372 eligible women aged
30-59 years
Allocated to usual care control group health
education, 56 clusters, 30167 women
Allocated to single round VIA screening by
nurses, 57 clusters, 48 225 women
Colposcopy/directed biopsy for screen ve women
Cryotherapy/LEEP/conization for CIN
Diagnosis treatment of invasive cancer
Diagnosis treatment of invasive cancer
Follow-up of women for cervical cancer incidence
and deaths
Comparison of cervical cancer incidence and
deaths in the VIA and Control Groups
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Interim results

• VIA Group, 48 225 women
• 32 340 (67) received VIA screening
• 3 088 (9.5) women screened positive
• 1 882 (5.8) had CIN 1 lesions
• 278 (8.6) had biopsy
• 239 (0.7) had CIN 2 3 lesions
• 75 with CIN received treatment
• Follow-up for cervical cancer incidence and
  mortality continuing
• Control Group, 30 167 women
• Follow-up for cervical cancer incidence and
  mortality continuing
• An interim analysis of final outcomes at the end
  of 2006

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Cost-Effectiveness of Cervical Cancer Screening
in Five Developing Countries
The most cost-effective strategies were those
that required the fewest visits, resulting in
improved follow-up testing and treatment.
Screening women once in their lifetime, at age
35, with a one- or two-visit screening strategy
involving visual inspection of the cervix with
acetic acid or DNA testing for human
papillomavirus (HPV) in cervical cell samples,
reduced the lifetime risk of cancer by
approximately 25 - 36 , and cost less than 500
per year of life saved. Relative cancer risk
declined by an additional 40 with two
screenings (at ages 35 and 40), resulting in a
cost per year of life saved that was less than
each country's per capita gross domestic product
a very cost-effective result, according to the
Commission on Macroeconomics and Health.
Goldie et al., 2005 N Engl J Med 353 20 2158-68
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Comparative efficacy of visual inspection with
acetic acid, HPV testing and conventional
cytology in cervical cancer screening a
randomized intervention trial in Maharashtra
State, India
Tata Memorial Centre (TMC), Mumbai, India Nargis
Dutt Memorial Cancer Hospital (NCMCH), Barshi,
IndiaInternational Agency for Research Cancer
(WHO-IARC), Lyon, France
Supported by the Bill Melinda Gates Foundation
through the ACCP
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Primary Objectives

• To evaluate the reduction in cervical cancer
  incidence and mortality associated with a single
  round of screening with visual inspection with
  acetic acid (VIA) or cytology or HPV testing, as
  compared to a control group with no screening
• To evaluate the cost-effectiveness (CE) of the
  above three approaches

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FLOW CHART OF THE STUDY DESIGN AND FINDINGS
Collaboration with Tata Memorial Centre, Mumbai
and NDMCH, Barshi
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Stage of disease by group and detection mode